Primary Hyperaldosteroneism (Primary Aldosteronism)

Overview

Primary hyperaldosteronism (also called primary aldosteronism or Conn’s syndrome) is a hormonal disorder in which one or both adrenal glands produce excess aldosterone, a hormone that regulates sodium and potassium balance and blood pressure. The over‑production leads to sodium retention, potassium loss, fluid overload, and consequently hypertension that often is resistant to standard antihypertensive therapy.

Most cases are caused by either:

• Aldosterone‑producing adrenal adenoma (APA) – a benign tumor.
• Bilateral adrenal hyperplasia (BAH) – diffuse over‑growth of adrenal tissue.

Less common causes include adrenal carcinoma, glucocorticoid‑remediable aldosteronism, and rare genetic mutations.

Reference: Mayo Clinic; NIH [1], [2].

Symptoms Checklist

• ☐ Persistent high blood pressure (often >150/100 mmHg)
• ☐ Headaches, especially in the morning
• ☐ Muscle weakness or cramps
• ☐ Frequent urination (polyuria) and increased thirst (polydipsia)
• ☐ Fatigue or feeling “off”
• ☐ Numbness or tingling (due to low potassium)
• ☐ Palpitations or irregular heartbeats (arrhythmias)
• ☐ Unexplained weight gain from fluid retention

Risk Factors

• Age > 40 years (most diagnoses are made in middle‑aged adults)
• Family history of hypertension or known adrenal disorders
• Existing resistant hypertension (BP that remains >140/90 mmHg despite ≥3 antihypertensive drugs)
• Female sex – slightly higher prevalence in women
• Certain genetic syndromes (e.g., familial hyperaldosteronism type I)

Diagnosis

Diagnosing primary hyperaldosteronism involves a stepwise approach:

1. Screening tests
   • Plasma aldosterone concentration (PAC) and plasma renin activity (PRA) or direct renin concentration. A PAC/PRA ratio >20–30 (depending on assay) is suggestive.
   • Patients should be off interfering meds (spironolactone, eplerenone, ACE inhibitors, ARBs, diuretics) for 2–4 weeks if possible, and maintain normal potassium.
2. Confirmatory testing (if screening is positive)
   • Saline infusion test
   • Captopril challenge
   • Fludrocortisone suppression test
   These tests verify autonomous aldosterone secretion.
3. Subtype localization
   • Adrenal computed tomography (CT) or magnetic resonance imaging (MRI) to identify adenomas.
   • Adrenal vein sampling (AVS) – the gold standard to differentiate unilateral (adenoma) from bilateral hyperplasia, especially when imaging is equivocal.

References: Cleveland Clinic [3]; Johns Hopkins [4].

Treatment Options

Medical Therapy

• Mineralocorticoid receptor antagonists (MRAs) – first‑line for bilateral hyperplasia:
  • Spironolactone (starting 25 mg daily, titrated up to 200 mg)
  • Eplerenone (25–50 mg daily, up to 100 mg)
• Potassium supplementation if hypokalemia persists.
• Adjust antihypertensive regimen – calcium channel blockers or β‑blockers can be added while MRAs take effect.

Surgical Therapy

• Laparoscopic adrenalectomy – indicated for unilateral aldosterone‑producing adenoma. Success rates >90 % for curing hypertension or markedly reducing medication burden.
• Post‑operative monitoring of potassium and blood pressure is essential.

Lifestyle / Home Measures

• Low‑sodium diet (≤1,500 mg Na⁺/day) to blunt aldosterone‑mediated sodium retention.
• Potassium‑rich foods (bananas, oranges, leafy greens) if levels are low.
• Regular blood‑pressure self‑monitoring.
• Weight control and regular aerobic exercise.

Prevention

Because primary hyperaldosteronism is largely intrinsic to adrenal pathology, true primary prevention is limited. However, the following measures can reduce the impact and help detect it early:

• Routine blood‑pressure checks—especially if you have resistant hypertension.
• Early evaluation of unexplained hypokalemia.
• Limit excessive sodium intake, which can exacerbate hypertension.
• Maintain a healthy weight and active lifestyle to lessen overall cardiovascular risk.

Living With Primary Hyperaldosteronism

• Medication adherence – take MRAs exactly as prescribed; missing doses can cause rapid rise in blood pressure.
• Monitor electrolytes – periodic labs (every 3–6 months) for potassium, sodium, creatinine.
• Blood‑pressure log – record readings twice daily; share trends with your provider.
• Dietary tips
  • Read nutrition labels; aim for < 1 g of salt per serving.
  • Choose fresh, unprocessed foods over canned or processed products.
• Physical activity – at least 150 minutes of moderate‑intensity aerobic exercise per week, as tolerated.
• Stress management – chronic stress can raise blood pressure; consider yoga, meditation, or counseling.
• Follow‑up schedule – endocrinology or hypertension specialist every 6–12 months, or sooner after medication changes.

When to Seek Emergency Care

If you experience any of the following, call 911 or go to the nearest emergency department:

• Severe, sudden headache or visual changes.
• Chest pain, shortness of breath, or palpitations suggestive of a cardiac event.
• Sudden weakness, numbness, or paralysis (possible severe hypokalemia).
• Blood pressure >180/120 mmHg with symptoms (hypertensive emergency).