Primary hyperaldosteronism is confirmed in a 48-year-old hypertensive man. Adrenal CT shows bilateral adrenal hyperplasia. Adrenal venous sampling confirms bilateral aldosterone hypersecretion. Which management is most appropriate?

• A Spironolactone (mineralocorticoid receptor antagonist) ✓
• B Bilateral adrenalectomy
• C Left adrenalectomy only
• D Amiloride alone

Explanation

In bilateral adrenal hyperplasia (idiopathic hyperaldosteronism), bilateral adrenalectomy is not indicated because it rarely cures hypertension and carries significant morbidity. Medical therapy with a mineralocorticoid receptor antagonist — spironolactone (first-line) or eplerenone — is the standard of care. Spironolactone effectively controls blood pressure and corrects hypokalemia. Surgery is reserved for unilateral adenoma or unilateral hyperplasia confirmed by adrenal venous sampling.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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