A 42-year-old woman with resistant hypertension (BP 175/110 mmHg on 3 antihypertensives including a diuretic) undergoes workup. Plasma aldosterone-to-renin ratio is 42 (elevated). CT adrenals are normal (bilateral). Saline infusion test fails to suppress aldosterone. Adrenal vein sampling confirms bilateral hypersecretion. What is the treatment of choice for bilateral primary hyperaldosteronism?

• A Mineralocorticoid receptor antagonist (spironolactone or eplerenone) ✓
• B Bilateral laparoscopic adrenalectomy
• C ACE inhibitor + calcium channel blocker combination
• D Fludrocortisone supplementation to suppress ACTH

Explanation

Bilateral primary hyperaldosteronism (bilateral adrenal hyperplasia/idiopathic hyperaldosteronism) is managed medically with a mineralocorticoid receptor antagonist (MRA) — spironolactone (first-line) or eplerenone (used when gynecomastia/menstrual irregularities limit spironolactone). Surgery is indicated only for unilateral adenoma confirmed by AVS. Bilateral adrenalectomy would cause Addison's disease. Fludrocortisone suppresses ACTH-dependent forms but is a mineralocorticoid agonist and would worsen hyperaldosteronism features.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.