A 62-year-old man with resistant hypertension (BP 165/98 mmHg on 3 antihypertensives including a diuretic at maximal doses) is found to have a serum potassium of 2.9 mEq/L. Plasma aldosterone-to-renin ratio is markedly elevated. CT adrenals show a right adrenal adenoma 1.8 cm. What is the definitive management?
- A Adrenal vein sampling to confirm lateralisation, followed by laparoscopic right adrenalectomy ✓
- B Lifelong spironolactone without surgery
- C CT-guided adrenal biopsy for histological confirmation
- D Proceed directly to right adrenalectomy based on CT imaging without AVS
Explanation
Primary hyperaldosteronism (PA) with a unilateral adenoma is potentially curable by laparoscopic adrenalectomy, but adrenal vein sampling (AVS) is recommended before surgery in most patients with PA (especially age >35 or bilateral adrenal abnormalities on CT) to confirm biochemical lateralisation of aldosterone excess, as CT has up to 40% false-positive and false-negative rates in PA. AVS confirming right-sided excess validates right adrenalectomy. CT-guided biopsy is not indicated for functional tumours. Spironolactone is the medical alternative when surgery is not possible.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.