Snapshot A 33-year-old woman returns to your clinic for continued management of her hypertension. She reports compliance with lifestyle modifications and prescribed anti-hypertensive medications including lisinopril, metoprolol, and losartan. She reports feeling fatigued and has noted slight abdominal distention. Her blood pressure at this visit is 155/92 mmHg. Serum laboratory tests show potassium 3.1 mEq/L and sodium 144 mEq/L. Introduction Overview primary hyperaldosteronism is a clinical condition caused by excessive and unregulated aldosterone secretion from the adrenal gland, usually from either an adrenal adenoma or adrenal hyperplasia presents with hypertension that is refractory to medical treatments treatment is adrenalectomy if caused from an adrenal adenoma and medical therapy if cause by adrenal hyperplasia Epidemiology Incidence ~10% of patients with hypertension 2/3 due to adrenal adenoma demographics more common in women 1/3 due to adrenal hyperplasia demographics more common in African Americans Usually between the ages of 30-50 Etiology Pathophysiology mechanism aldosterone secretion independent of the renin-angiotensin system aldosterone-secreting adenoma of the zona glomerulosa (Conn syndrome) bilateral adrenal hyperplasia adrenal carcinoma Presentation Symptoms headache muscle weakness (due to hypokalemia) palpitations polyuria (due to hypokalemic nephropathy) polydipsia nausea and vomiting Physical exam hypertension refractory to medical treatments arrhythmia abdominal distention no peripheral edema (due to aldosterone escape) but may be present in severe cases Imaging CT indications to evaluate the cuase of primary hyperaldosteronism can differentiate between hyperplasia, adenoma, and carcinoma Studies Labs serum hypokalemia mild hypernatremia metabolic alkalosis Invasive studies plasma aldosterone to plasma renin screening test positive screen shows an inappropriately high ratio ≥ 30 saline infusion test definitive diagnosis test persistently elevated aldosterone ≥ 8.5 ng/dL is diagnostic adrenal venous sampling measure aldosterone level unilateral elevation indicates adenoma bilateral elevation indicates bilateral hyperplasia Differential Secondary hyperaldosteronism key distinguishing factor elevated renin Adrenal incidentaloma key distinguishing factor nonfunctioning adrenal neoplasm Treatment Pharmacologic spironolactone or eplerenone indications hypertension bilateral adrenal hyperplasia Operative adrenalectomy indications unilateral adenoma Complications Hypertensive crisis, cardiomyopathy, and nephropathy Stroke