Broadening Primary Aldosteronism Screening: Alignment Across Contemporary Guidelines

Fewer than 2% of eligible patients are screened for primary aldosteronism, despite evidence that early detection and targeted therapy are associated with lower cardiovascular and kidney morbidity. Recent updates to major hypertension and endocrine guidelines reflect growing recognition that primary aldosteronism is far more prevalent than previously understood and that broader, more practical screening approaches are needed. These recommendations increasingly extend screening beyond resistant hypertension to adults with stage 2 hypertension and even to all individuals with hypertension. They also aim to lower barriers to testing through more flexible guidance on antihypertensive medication management, reaffirm the aldosterone-to-renin ratio as the preferred initial test, and provide more standardized criteria for interpretation. Supporting evidence includes epidemiological data demonstrating a continuum of renin-independent aldosterone production across blood pressure categories, strong associations between untreated primary aldosteronism and adverse cardiovascular and kidney outcomes independent of blood pressure, and favorable cost-effectiveness of screening even in lower-risk groups. Implementation remains the principal challenge, with obstacles spanning patient, clinician, and health system levels. Emerging electronic health record strategies, including electronic phenotyping and integrated clinical decision support, have shown early promise in increasing screening uptake and streamlining diagnostic pathways. Collectively, contemporary guideline updates and implementation innovations represent a shift toward earlier and broader detection of primary aldosteronism, with the potential to reduce preventable cardiorenal disease across the hypertensive population.