Primary hyperaldosteronism (PA) is the most common secondary form of hypertension in middle-age adults. Its harmful effects exceed that of essential hypertension. Once diagnosed, treatment hinges on whether aldosterone secretion is unilateral or bilateral, as the former can be effectively treated with adrenalectomy while the latter is treated medically with mineralocorticoid receptor antagonists such as spironolactone or eplerenone. Adrenal vein sampling (AVS) is critical in this determination. There is wide variation in how AVS is performed, including whether to use synthetic adrenocorticotropic hormone stimulation and where the catheter tip should be placed during left adrenal gland sampling. Additionally, some institutions and guidelines omit AVS in young patients (below an age threshold ranging from 35 to 40 years old) with unilateral adrenal findings on cross-sectional imaging. In this article, we provide background on primary hyperaldosteronism and performance of AVS and then summarize the evidence supporting best practices for these three areas of controversy regarding how and when to perform AVS.
