Rethinking Primary Aldosteronism: The 2025 John H. Laragh Research Award

Dr John Laragh, a pioneer in the field of hypertension, held a fundamental belief in the need to challenge existing dogmas in medicine to enhance our scientific understanding of disease and advance patient care. Perhaps in no area of hypertension does this ring truer with than primary aldosteronism (PA). Following its initial description in the mid-1950s with an initial surge in diagnoses soon thereafter, PA was ultimately relegated to be considered a "zebra" of hypertension felt to be responsible for only a small percentage of cases. In turn, diagnostic and treatment pathways went largely unchanged for decades. However, recent years have witnessed a renaissance in PA sparked by a number of scientific breakthroughs that have re-fashioned many long-held paradigms. Such breakthroughs include the recognition that classically defined PA is highly prevalent and that an even broader spectrum of milder forms of dysregulated aldosterone production (subclinical PA) goes completely unrecognized in modern-day clinical practice. Further, a number of pitfalls have recently been exposed across all steps of traditional PA diagnostic pathways, explaining many prior missed cases and missed opportunities. Acknowledging these pitfalls may allow for streamlined, practical, and evidence-based algorithms in the future to enhance disease detection. Finally, treatment approaches are now evolving with new strategies to better guide existing medical therapies along with emerging novel therapeutic options which may transform PA management in the future. This review discusses these recent advances in our understanding of PA and sheds light on what the future of PA management may entail.