As evidenced by this debate, controversy persists as to the true prevalence of primary aldosteronism (PA) and, perhaps more importantly, concerns regarding the clinical rationale of evaluating large numbers of hypertensive patients for evidence of aldosterone excess. In regard to the former controversy, it has been suggested that reports of a high prevalence of PA exaggerate the true value for a variety of methodologic shortcomings, including overreliance on the plasma aldosterone/plasma renin ratio (ARR) to estimate the prevalence of PA; a selection bias from estimating the general prevalence of PA based on patients referred to hypertension specialty clinics; and because of inappropriately considering idiopathic hyperaldosteronism (presumed secondary to adrenal hyperplasia) to be a type of PA. Suggestions to broadly screen hypertensive patients for PA have led to the latter controversy as to whether the costs and risks of potentially evaluating large numbers of hypertensive patients for the presence of PA are clinically justified. The controversies are obviously related but especially so for clinicians treating hypertension, because they reflect different strategies as to how and when to screen patients for PA.
