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Primary aldosteronism Mostly asymptomatic Spontaneous or diureticprovoked hypokalaemia AF Disproportionate HMOD Muscle weakness and tetany Family history of primary aldosteronism, early onset hypertension and/or stroke Adrenal incidentaloma Signs and symptoms Diagnosis Pathophysiology Treatment Aldosterone-renin ratio (ARR) Confirmatory tests (e.g. saline suppression test) Adrenal vein sampling or functional imaging Genetic testing Aldosterone-producing adenoma Familial forms due to germline mutations Bilateral hyperplasia Medical: mineralocorticoid receptor antagonists Surgical: unilateral adrenalectomy Figure 13 Summary of primary aldosteronism as a common form of secondary hypertension. AF, atrial fibrillation; HMOD, hypertension-mediated organ damage. Table 13 Optional tests that should be used to screen for secondary hypertension in the presence of suggestive signs, symptoms, or medical history Cause of secondary hypertension Screening test Primary aldosteronism Aldosterone-to-renin ratio Helpful information can also be provided by reviewing prior potassium levels (hypokalaemia increases the likelihood of coexistent primary hyperaldosteronism) Renovascular hypertension Renal doppler ultrasound Abdominal CT angiogram or MRI Phaeochromocytoma/paraganglioma 24 h urinary and/or plasma metanephrine and normetanephrine Obstructive sleep apnoea syndrome Overnight ambulatory polysomnography Renal parenchymal disease Plasma creatinine, sodium, and potassium eGFR Urine dipstick for blood and protein Urinary albumin-to-creatinine ratio Renal ultrasound Cushing’s syndrome 24 h urinary free cortisol Low-dose dexamethasone suppression test Thyroid disease (hyper- or hypothyroidism) TSH Hyperparathyroidism Parathyroid hormone Calcium and phosphate Coarctation of the aorta Echocardiogram Aortic CT angiogram © ESC 2024 CT, computed tomography; eGFR, estimated glomerular filtration rate; MRI, magnetic resonance imaging; TSH, thyroid-stimulating hormone. Downloaded from academic.oup.com/eurheartj/article/45/38/3912/7741010 by guest on 07 October 2026