A 55-year-old man with resistant hypertension (BP 158/96 mmHg on maximum doses of ACE inhibitor, amlodipine, and chlorthalidone) undergoes further workup. Serum aldosterone is 28 ng/dL and plasma renin activity is 0.4 ng/mL/hour, giving an aldosterone-renin ratio of 70 (> 30 is significant). CT adrenals show bilateral adrenal hyperplasia. What is the most appropriate management?

• A Bilateral adrenalectomy as definitive treatment
• B Adrenal vein sampling to distinguish bilateral hyperplasia from unilateral adenoma before deciding surgery vs. mineralocorticoid receptor antagonist ✓
• C Add spironolactone without further investigation as CT confirms bilateral disease
• D Start fludrocortisone suppression test before any treatment

Explanation

CT adrenals can miss small adenomas and misidentify bilateral hyperplasia. Adrenal vein sampling (AVS) is the gold standard test to lateralise aldosterone excess in primary hyperaldosteronism — bilateral hyperplasia on CT does not exclude a unilateral adenoma amenable to curative adrenalectomy. Endocrine Society guidelines recommend AVS in all candidates considering surgery. If AVS confirms bilateral disease, medical therapy with mineralocorticoid receptor antagonists (spironolactone, eplerenone) is appropriate.

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

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Written and medically reviewed by the StethoPrep medical team.