Screen All With Hypertension for Primary Aldosteronism

San Francisco — All individuals with hypertension should be screened for primary aldosteronism (PA), according to a new clinical practice guideline from the Endocrine Society.

The recommendation is to screen everyone with hypertension by measuring aldosterone and renin and to use the aldosterone to renin ratio to guide clinical care with either medication or surgery. Potassium should also be measured to aid in aldosterone interpretation. Mineralocorticoid receptor antagonists (MRAs) are the preferred medical treatment. 

The document was posted online July 14, 2025 in the Journal of Clinical Endocrinology and Metabolism and presented on July 15, 2025 at ENDO 2025: The Endocrine Society Annual Meeting. It was endorsed by the American Association of Clinical Endocrinology, American Heart Association, European Society of Endocrinology, European Society of Hypertension, International Society of Hypertension, and the Primary Aldosteronism Foundation. The European Society of Cardiology made a similar recommendation in 2024. 

PA: Under-Recognized and Under-Treated

In PA, the adrenal gland over-produces aldosterone independently of renin, a common phenomenon in the setting of modern-day high-salt diets. This leads to renal sodium retention, volume expansion, and elevated blood pressure, with variable potassium loss. Aldosterone also causes direct damage to the entire cardiorenal system by acting on mineralocorticoid receptors in these target organs. 

“If you look at cardiovascular disease in individuals with [PA] as compared to those with primary hypertension, they have an increased risk of stroke, coronary artery disease, atrial fibrillation, heart failure, and renal disease,” the document’s lead author, Gail K. Adler, MD, PhD, chief of the cardiovascular endocrinology section at Brigham and Women’s Hospital, Boston, Massachusetts, told Medscape Medical News. 

The condition can be lateralizing, typically caused by an adrenal adenoma that can be surgically removed, or bilateral, commonly resulting from multiple adrenal microadenomas, for which MRAs are effective treatment. 

Currently, PA is vastly under-recognized and under-treated. Studies conducted over the past couple of decades suggest that PA prevalence is 5.9% among people with hypertension seen in primary care, 16.2% of younger adults aged 18-40 years with hypertension, 28.1% among adults with both hypertension and hypokalemia, 42% of those with hypertension and atrial fibrillation, and between 11.3% and 19.1% of those with hypertension and type 2 diabetes, according to the document. 

Yet, in a study of US Veterans published in 2020, PA screening rates were less than 2% even among those with treatment-resistant hypertension. No improvements in screening rates were found in a more recent follow-up study from the same team. 

Meta-analyses have shown that, compared to people with primary hypertension, those with PA have more than twice the risk for stroke and kidney disease, more than triple for atrial fibrillation, and twice the risk for heart failure. The goal of this new guideline, Adler said, “is to make it easy to diagnose [PA] and to start appropriate aldosterone-targeted therapy to reduce the excess cardiovascular, stroke, and renal morbidity associated with [PA]. It’s so easy to treat. Part of the problem in the past is we made it so hard to diagnose.” 

Universal screening of people with hypertension for PA is already common practice in Japan, Australia, and China, where studies have demonstrated cost-effectiveness derived from the reduction in long-term complications, the authors point out. 

The Recommendations

The Endocrine Society makes ten conditional recommendations all worded as “we suggest” based on the low level of evidence per the Grading of Recommendations Assessment, Development and Evaluations Evidence to Decision framework. 

1. PA screening is suggested in all individuals with hypertension.
2. In individuals with hypertension and PA, PA-specific therapy is suggested. Medical treatment with MRAs is preferable to nonspecific antihypertensive therapy. For individuals with lateralizing PA who are surgical candidates and desire surgery, unilateral adrenalectomy is preferred.
3. Screening for PA should include measurements of serum/plasma aldosterone concentration and plasma renin (concentration or activity).

A positive screen is defined as both a low renin level with inappropriately high aldosterone and an elevated aldosterone to renin ratio. Cutoffs for both values differ by assay and are provided in the document. 

Potassium should be measured with aldosterone to aid in interpretation since low potassium can lead to falsely low aldosterone readings. 

Management of interfering medications depends on individual safety and feasibility. The document provides strategies for both minimal withdrawal and no-withdrawal prior to screening. “Before, we said stop all antihypertensives. It was so difficult. Now we say just test them,” Adler commented. 

4. In individuals who screen positive for PA, aldosterone suppression testing is suggested in situations where screening results indicate an intermediate probability of lateralizing PA and the patient desires surgery.
5. In individuals with PA, medical or surgical therapy is suggested, with the choice based on lateralization of aldosterone hypersecretion and candidacy for surgery.
6. For those with PA considering surgery, computed tomography scanning and adrenal venous sampling are suggested prior to deciding on the treatment approach.
7. For individuals with PA in whom hypertension is not controlled and renin is suppressed despite PA-specific medical therapy, a dose increase is suggested to raise renin levels.
8. For those with PA and adrenal adenoma, a dexamethasone suppression test is suggested.
9. In individuals with PA receiving PA-specific medical therapy, spironolactone is preferred over other MRAs due to its low cost and widespread availability.
10. For those with PA receiving PA-specific medical therapy, MRAs are preferred rather than epithelial sodium-channel inhibitors (amiloride, triamterene).

Asked to comment, Jordana Cohen, MD, associate professor of medicine and epidemiology at the Perelman School of Medicine, University of Pennsylvania, Philadelphia, told Medscape Medical News, “We do a very poor job of screening for PA and, as a result, it is being missed in the vast majority of cases. More people are screened for pheochromocytoma, even though it’s far rarer, than for [PA]. This really needs to change. I think the new guidelines are an important step toward simplifying and removing barriers to screening that have the potential to improve screening rates, assuming they are implemented.”

Cohen, who led the veterans affairs (VA) studies that found the extremely low PA screening rates, added that — in contrast to previous PA guidelines — this one “does a great job of providing guidance about no longer holding medications in most cases — based on growing evidence to support this — how to interpret the results, and when further testing may be needed.” 

Also asked to comment, Richard J. Auchus, MD, chief of the Endocrinology & Metabolism Section at the Ann Arbor VA Medical Center, Michigan, told Medscape Medical News he generally supports the guideline, while also expressing some caveats about universally screening everyone with hypertension. 

“I definitely agree with screening everyone who fails two antihypertensive drugs. Nobody on the planet is going to argue that patients with difficult-to-control hypertension shouldn’t be screened. And the truth is that about two-thirds of people with hypertension are not controlled, and many are already taking two drugs. I don’t disagree with the guidelines, but I do think there are some people, like a 70-year-old newly diagnosed with hypertension who you put on 12.5 mg of hydrochlorothiazide and now their blood pressure is normal, who might not need to be screened. If we screen everybody, it’s going to add to the cost of healthcare in the short-term, but maybe not in the long-term.”

“I can see both sides,” Auchus added. “We want to catch people early on to minimize the end organ damage from being on the wrong drug. So, I think the risk benefit ratio is probably in favor of screening everybody.”

Adler receives research funding from the National Institutes of Health and Tersus Life Sciences, LLC. Auchus and Cohen have no relevant disclosures. 

Miriam E. Tucker is a freelance journalist based in the Washington DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X (formerly Twitter) @MiriamETucker and BlueSky @miriametucker.bsky.social