A 45-year-old woman has resistant hypertension — BP remains 162/98 mmHg despite three maximally tolerated antihypertensives including a thiazide diuretic. Aldosterone-renin ratio (ARR) is markedly elevated. Adrenal CT shows a left-sided 1.4 cm adenoma. Adrenal vein sampling (AVS) confirms left-sided aldosterone excess. What is the definitive treatment?

• A Lifetime spironolactone and optimise antihypertensives
• B Bilateral adrenalectomy given adrenal hyperplasia risk
• C Eplerenone monotherapy titrated to blood pressure control
• D Left laparoscopic adrenalectomy ✓

Explanation

This patient has confirmed primary hyperaldosteronism (Conn's syndrome) with unilateral left adrenal adenoma confirmed on AVS — the gold standard for lateralisation. For unilateral aldosterone-producing adenoma, laparoscopic adrenalectomy is the definitive treatment and is associated with biochemical cure in > 90% and clinical cure (BP normalisation off medications) in approximately 50–70% of patients. AVS confirmation is mandatory before surgery to exclude bilateral disease that would be better managed with mineralocorticoid receptor antagonists. Medical therapy with spironolactone is reserved for bilateral disease or patients unfit for surgery.

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

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Written and medically reviewed by the StethoPrep medical team.