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endo.primary_aldosteronism.v1

Primary aldosteronism (Conn syndrome)

endocrinologychronicsubacuteadultoutpatientinpatienttransition
Start encounter →Print handoutPRODUCTION

Primary aldosteronism — most common reversible secondary HTN; ARR screen → confirm → AVS → adrenalectomy or MRA. Wash out interfering antihypertensives before ARR (4 wks off MRA / amiloride; verapamil / hydralazine / α-blocker acceptable). Glucocorticoid-remediable aldosteronism (FH-1) responds to dexamethasone; consider in young / family history. Open: manifest, problem-package, RxCUI verification, ARR + AVS lateralization calculators absent, tests.

Entry points (5)

  • symptom
    Resistant HTN (≥3 antihypertensives incl diuretic) at goal not achieved (ADA 2026)
    resistant_htn
  • lab_abnormality
    Spontaneous hypokalemia or thiazide-induced disproportionate hypokalemia (ADA 2026)
    spontaneous_or_thiazide_hypokalemia
  • symptom
    HTN onset <30 yr (ADA 2026)
    htn_under_30
  • imaging
    Adrenal incidentaloma with HTN (ADA 2026)
    adrenal_incidentaloma
  • history
    Family history of PA or stroke at <40 yr (familial type 1) (ADA 2026)
    family_history_pa_or_stroke_young

Required inputs (12)

  • agerequired
    demographic • used at CONTEXT
    Younger patients more likely to benefit from surgery (ADA 2026)
  • sbprequired
    vital • used at CONTEXT
    Severity and response monitoring (ADA 2026)
  • dbprequired
    vital • used at CONTEXT
    Severity (ADA 2026)
  • serum_potassiumrequired
    lab • used at INITIAL_WORKUP
    Hypokalemia (often present); replete before ARR (ADA 2026)
  • aldosterone_renin_ratiorequired
    lab • used at INITIAL_WORKUP
    Screening test (>20 with aldosterone >15 ng/dL suspicious) (ADA 2026)
  • creatinine_egfrrequired
    lab • used at INITIAL_WORKUP
    Renin interpretation; saline suppression cautious (ADA 2026)
  • plasma_aldosterone_post_saline
    lab • used at BRANCHING_WORKUP
    Confirmatory saline suppression (>10 ng/dL after 2L NS positive) (ADA 2026)
  • 24h_urine_aldosterone
    lab • used at BRANCHING_WORKUP
    Alternative confirmatory (>12 µg/day with sodium repletion) (ADA 2026)
  • adrenal_ctrequired
    imaging • used at BRANCHING_WORKUP
    Anatomical assessment after biochemical confirmation (ADA 2026)
  • adrenal_vein_sampling
    imaging • used at BRANCHING_WORKUP
    Lateralization for surgical candidate (gold standard for subtype) (ADA 2026)
  • antihypertensive_regimenrequired
    history • used at CONTEXT
    Wash out / substitute interfering drugs before ARR (especially MRA) (ADA 2026)
  • current_medsrequired
    medication • used at CONTEXT
    Drug interference with ARR (ADA 2026)

12-phase flow (12)

  1. 1FRAME
    Confirm PA (autonomous aldosterone with suppressed renin); rule out secondary aldosteronism (ADA 2026)
    inputs: aldosterone_renin_ratio
    advance: Biochemical confirmation
  2. 2ENTRY
    Resistant HTN, spontaneous hypoK, HTN <30, adrenal incidentaloma, family history (ADA 2026)
    inputs: age
    advance: Engine entered
  3. 3CONTEXT
    BP regimen, OSA, K+, comorbidity, drug interference review (ADA 2026)
    inputs: antihypertensive_regimen, serum_potassium, current_meds
    advance: Context complete
  4. 4RED_FLAGS
    Severe hypoK (weakness / arrhythmia), malignant HTN, hypertensive emergency (ADA 2026)
    inputs: sbp, serum_potassium
    actions: hypokalemia, htn_emergency
    advance: Stabilised
  5. 5INITIAL_WORKUP
    BMP, K+, ARR (preferably off MRA / amiloride for 4 wks; switch to verapamil / hydralazine / α-blocker if needed); may need K repletion before ARR (ADA 2026)
    inputs: serum_potassium, aldosterone_renin_ratio, creatinine_egfr
    actions: panel.renal, specialty.primary_aldosteronism
    advance: ARR result
  6. 6BRANCHING_WORKUP
    Confirmatory test (saline infusion, oral salt loading, fludrocortisone, captopril); adrenal CT; AVS for surgical candidate; genetic testing if familial features (ADA 2026)
    inputs: plasma_aldosterone_post_saline, adrenal_ct, adrenal_vein_sampling
    advance: Subtype assigned
  7. 7DIFFERENTIAL
    APA vs bilateral adrenal hyperplasia vs unilateral hyperplasia vs glucocorticoid-remediable vs adrenal carcinoma (ADA 2026)
    advance: Subtype assigned
  8. 8RISK_STRATIFICATION
    Surgical candidacy (unilateral + young + medical fit); medical management for bilateral or non-surgical (ADA 2026)
    inputs: age, creatinine_egfr
    advance: Path chosen
  9. 9TREATMENT
    Surgical: laparoscopic adrenalectomy for unilateral. Medical: spironolactone first-line; eplerenone if SE; amiloride / triamterene; combine with chlorthalidone / CCB / ACEi as needed; replete K; lifestyle (ADA 2026)
    inputs: serum_potassium, creatinine_egfr
    advance: Plan documented
  10. 10DISPOSITION
    Outpatient endo; admit hypoK emergency or malignant HTN (ADA 2026)
    advance: Disposition documented
  11. 11MONITORING
    BP home log, K+, creatinine, gynecomastia / breast tenderness on spironolactone, post-op ARR (ADA 2026)
    inputs: serum_potassium, creatinine_egfr
    advance: Schedule documented
  12. 12FOLLOWUP
    Endo q3–6 mo; cardiology / nephrology as needed; PASO classification post-op (ADA 2026)
    advance: Follow-up booked