Volume 30, Issue 169, March 2026

Primary aldosteronism in patients with resistant hypertension – diagnostic challenges and clinical implications

Aleksandra Lisowska^1♦, Oliwia Jerzyńska², Pola Sitek¹, Dariusz Szołtys¹, Karolina Zygoń Komendarczyk¹, Katarzyna Oberska¹, Michalina Adamczyk¹, Sandra Olewińska¹, Tola Kotkiewicz¹, Yelyzaveta Petrenko³

¹Municipal Hospital in Siemianowice Śląskie, Siemianowice Śląskie, Poland
²University Clinical Hospital No. 2, Pomeranian Medical University in Szczecin, Szczecin, Poland
³Municipal Hospital Complex in Chorzów, Chorzów, Poland

^♦Corresponding author
Aleksandra Lisowska, Municipal Hospital in Siemianowice Śląskie, Siemianowice Śląskie, Poland

ABSTRACT

Primary aldosteronism (PA) has become increasingly recognised as a frequent and clinically important cause of resistant hypertension. In the past, the importance of PA was marginalised, but the newest research indicates that it may be present in a significant number of patients with persistently uncontrolled hypertension, despite the use of multiple antihypertensive drugs. The main reason for treatment resistance is aldosterone excess. It leads to volume expansion, vascular remodelling, endothelial dysfunction, and direct organ damage, which limit the effectiveness of standard antihypertensive therapies. Diagnostic evaluation in patients with resistant hypertension is challenging. One main reason is the interference from medications during hormonal testing, along with variations in aldosterone-renin ratio (ARR) results. The limitations of confirmatory procedures and the common occurrence of normokalemic disease must also be considered during diagnosis. Relying only on ARR and strict diagnostic guidelines can slow the diagnosis of primary aldosteronism (PA). This leads to a longer exposure to excess aldosterone, which raises the chances of heart, kidney, and metabolic problems. Treatment options include mineralocorticoid receptor antagonists or adrenalectomy. These treatments help control blood pressure and lower overall cardiovascular risk. Furthermore, adrenalectomy can completely cure some cases. This review brings together current evidence on the prevalence, underlying causes, diagnostic challenges, and treatment implications of primary aldosteronism in patients with resistant hypertension. The key point is the need for individualised and clinically focused diagnostic approaches that combine biochemical data with clinical evaluation and suitable imaging.

Keywords: primary aldosteronism, resistant hypertension, aldosterone–renin ratio; secondary hypertension; mineralocorticoid receptor antagonists

Medical Science, 2026, 30, e47ms3806

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DOI: https://doi.org/10.54905/disssi.v30i169.e47ms3806

Published: 03 March 2026