Primary aldosteronism is the most common endocrine cause of hypertension, and is often associated with treatment-resistant hypertension. It is characterized by autonomous aldosterone production independent of renin activity, potassium level, or volume status. Its prevalence has been debated, and studies are fraught with limitations, including reliance on tests that do not confirm the diagnosis. It has been identified as a public health issue, and the urgency in identifying and treating it is heightened by its strong association with adverse kidney and cardiovascular outcomes. Multiple studies have pointed to limitations of our current screening strategies, which may be missing a great many patients who have the disease. In particular, newer evidence highlights shortcomings of the long-accepted screening strategy that uses the spot aldosterone-to-renin ratio. In this commentary, we review the current understanding of primary aldosteronism and the current landscape of screening practices. We will highlight the emerging evidence suggesting that renin-independent hyperaldosteronism is best viewed as a continuum that extends across the spectrum of blood pressure severity. We also describe a proposed approach to optimize case detection of primary aldosteronism.
