Resistant Hypertension for Nurse Practitioners Part 2: Primary Aldosteronism
Primary aldosteronism is one of the most common—and most frequently overlooked—causes of secondary hypertension. In patients with resistant hypertension, identifying excess aldosterone production can change both treatment decisions and referral planning.
In this episode, we discuss when to suspect primary aldosteronism, who should be screened, how to interpret the initial laboratory evaluation, and how these results can help determine whether a patient should be referred to endocrinology, nephrology, or cardiology. While this episode was originally recorded before the newest hypertension guidelines (released in 2025), the overall diagnostic approach remains highly relevant in primary care.
Updated July 2026: This page has been reviewed and updated to reflect current hypertension guideline recommendations. Since this episode was originally recorded, newer guidelines recommend broader screening for primary aldosteronism in appropriate patients with hypertension. The overall approach to recognizing and initiating the workup for primary aldosteronism discussed in this episode remains clinically relevant.
Key Clinical Takeaways - updated 7/2026
Primary aldosteronism is one of the most common and underrecognized causes of secondary hypertension.
Not all patients with primary aldosteronism have hypokalemia—normal potassium does not exclude the diagnosis.
Consider screening patients with resistant hypertension and other guideline-recommended indications, including appropriate patients with obstructive sleep apnea or stage 2 hypertension.
Initial screening includes plasma aldosterone concentration (PAC), plasma renin activity (PRA), and the aldosterone-to-renin ratio (ARR), which are interpreted together.
Interpretation can be affected by medications, particularly mineralocorticoid receptor antagonists (spironolactone and eplerenone), which should ideally be discontinued for at least 4 weeks before testing when clinically appropriate.
Patients with a positive screening test should undergo additional evaluation and/or referral for confirmatory testing.
Identifying primary aldosteronism can improve blood pressure control and reduce long-term cardiovascular risk.
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What You'll Learn about Primary Aldosteronism and Resistant Hypertension
00:58 – Why primary aldosteronism is an important cause of resistant hypertension
01:43 – Defining resistant hypertension and where primary aldosteronism fits into the evaluation
02:20 – Which specialists manage resistant hypertension and when to refer
03:35 – Aldosterone physiology and why excess aldosterone raises blood pressure
04:20 – Common causes of primary and secondary aldosteronism
05:45 – When to suspect primary aldosteronism in clinical practice
06:45 – Why normal potassium does not rule out primary aldosteronism
07:30 – Initial laboratory evaluation: aldosterone, renin, and the aldosterone-to-renin ratio (ARR)
08:35 – Interpreting screening results and determining the appropriate specialist referral
If you liked this post, also check out:
Looking for the newest hypertension recommendations?
Since this episode was originally published, new hypertension guidelines have been released. For an updated discussion of the latest recommendations—including the PREVENT calculator, single-pill combination therapy, primary aldosteronism screening, and home blood pressure monitoring—listen to:
→ New Hypertension Guidelines: Practical Updates with Dr. Jordy Cohen
Continue Learning
The Hypertension Management in Primary Care Course is part of the Real World NP Chronic Care Series, a comprehensive continuing education program designed specifically for nurse practitioners. Through case-based learning and practical clinical frameworks, you'll learn how to confidently diagnose, evaluate, and manage hypertension using current evidence and guideline-based recommendations.
The course has been peer-reviewed by hypertension specialists to help ensure the content reflects current best practices while remaining practical for everyday primary care.
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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In this week's video, I want to continue the conversation about resistant hypertension
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evaluation.
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And before I jump in, I just want to share that I have a brand new course coming up this
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fall slash winter, and it's all about chronic care management.
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It's the top three most common chronic conditions in primary care.
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So diabetes, hypertension, and CKD in terms of the medication management, as well
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as assessment and diagnostic workups for and management of monitoring and management
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of CKD.
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So if you want to join us or you want to learn more information, head over to
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realworldnp.com slash courses, and then we'll email you the first when there's more
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information coming out.
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So getting back into resistant hypertension now, I made a video, resistant
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hypertension part one.
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So definitely go watch that before you watch this one or in any order, I guess.
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But in that video, I talked about the steps to working up resistant
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hypertension, which just as a refresher is a patient who is on three or more
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hypertensive medications, including a diuretic that are optimized doses and
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they're still not at goal for their blood pressure.
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So in part one, I talked about all the different steps for evaluation and
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workup.
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And then this video, I'm delving a little bit more into a subset of
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investigation, which is high aldosterone.
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So hyper aldosteronism is an under recognized cause of resistant
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hypertension in primary care.
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And it is a place that I certainly have learned about more recently.
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And I want to not that I learned about more recently, but I'm doing a little bit
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more in my practice, getting comfortable with taking the step of evaluation,
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because it is under recognized.
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So and the rationale for well, first of all, you can just learn about this
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and not adopt these practices if you don't want to based on your personal
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comfort level of practice.
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However, this is important to know about as an etiology and can help you
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determine with a couple of simple blood tests who to refer to for help with
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resistant hypertension patient.
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So three referrals, three specialists can help us with resistant hypertension.
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So one is cardiology.
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Two is endocrine.
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If it's if it's thought to be an adrenal
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aldosterone related cause.
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And then the third one is renal because they can help for patients
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who have CKD with resistant hypertension.
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Those are the people you want to talk to.
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So doing this blood test can help us determine
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who is the best person to refer to if the patient's blood pressure
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is still not within goal, even though they're on all those meds. Right.
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OK, so at first, let's start with some basics. Quick refresher.
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So what are the adrenal glands? Right.
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Those are those endocrine glands that are on top of the kidneys
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and they release a number of hormones, aldosterone, of course,
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glucocorticoids, sex hormones and epinephrine.
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I have my notes here.
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That's why I'm taking a peek at my screen.
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So and then what is aldosterone?
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So aldosterone works in the kidneys and it helps with sodium
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reabsorption as well as potassium.
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And it's part of the renin and angiotensin system.
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That wonderful thing that you learned about in patho.
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Maybe you loved it, maybe you didn't.
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So why do we care about it?
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So if it's too high, it's going to cause resistant hypertension.
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What are the causes of that?
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So one of the causes, there's primary and secondary
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hyper aldosteronism.
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The first one, the most common one is idiopathic, meaning like we have no idea.
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We have normally looking, normally looking
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and normally sized adrenal glands on top of our kidneys.
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But for some reason that we don't understand,
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they're producing more aldosterone than they should.
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The next most common ones have to do with adrenal adenomas,
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little growths on top of the adrenal glands that are secreting
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aldosterone.
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And then also we can have things like pheochromocytoma,
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which is another type of growth and has its own specific symptoms
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as well as hypertension.
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I'm not going to get into that in this video,
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because I think that's a little bit information overload.
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But just keep in mind, pheochromocytoma is a potential option
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for high blood pressure, but it comes with a constellation of other symptoms.
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And then the other main causes for high aldosterone is it can be secondary,
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meaning it's not directly coming from the adrenal glands,
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but something is stimulating the adrenal glands to make more aldosterone.
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And the main causes for that are a carcinoma of some kind.
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Ovarian and renal are the most common causes.
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So those two can stimulate the adrenal glands to make more aldosterone
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or actually perhaps make more themselves.
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And actually, don't quote me on that.
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But having a tumor can cause that release of aldosterone.
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So when would you want to think about high aldosterone
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checking for this in a patient?
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So the reason I would check this is if somebody had resistant hypertension,
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I did the other workup that was available
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and we still couldn't figure it out before I sent them to a specialist,
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because that would help us determine who the best person is. Right.
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And so the other constellation of symptoms that can go along
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with high aldosterone are low potassium
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unrelated to any other medications that they take,
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unrelated to any other reason.
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They just happen to have low potassium and high blood pressure.
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And then the third one is metabolic alkalosis, signs of that,
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which you can see on the BMP a little bit.
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It's getting a little fancy, but
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that's that's the classic triad.
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But in the real world, most people do not have low potassium.
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So don't let that be a barrier for you.
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Let it be included in your resistant hypertension workup
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if you feel comfortable ordering and interpreting those labs.
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And again, if you don't, definitely seek out either continuing education
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or your colleagues or and or supervisor.
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So I guess just to throw in a couple of other symptoms,
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if you are thinking about a few chromocytoma, they have hypertension
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may or may not be resistant.
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They can have sweating, headaches.
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They can also have hyperglycemia or this like hypermetabolic state.
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But if you have like sweating and hypertension,
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you might think about a few chromocytoma included in your differential
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diagnosis, but again, treading lightly, getting support
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because that's a little bit of a zebra diagnosis that we're bringing in there.
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So not like jumping to that.
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And just know that they can also have paroxysmal symptoms as well.
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So if they have hypertension with like sweating and tachycardia
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and that kind of stuff here and there, definitely think about it.
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But and again, get some get some support with that.
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So for the workup.
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So if you're thinking about this as a potential workup,
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there's a first pass that we can do to let us think
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if there's a possibility, because it needs a number of confirmatory tests
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to make the diagnosis of hyperaldosteronism.
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But the first pass that we can make in primary care reasonably safely
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is a morning renin and aldosterone, two different labs,
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serum, renin and serum aldosterone.
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And it might be termed a little bit differently, depending on your lab.
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But what we're looking for is to see the patients
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with hyperaldosteronism will have a high aldosterone
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with a suppressed renin level.
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And that would be your kind of first clue of like, you know what?
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I think this person probably should see endocrine. Right.
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And that simple like the reason I'm making a video about this is, again,
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number one, it's under recognized.
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And two, we can pretty easily do those two blood tests
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to help us figure out what specialist to go to, because we all know
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referrals can take a long time for patients to get an appointment,
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to get there, to get worked up, et cetera, et cetera.
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And like I said, there's like a whole cascade of other lab tests
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and potentially an abdominal CT that might be involved
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to look at the adrenal glands itself.
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But I probably would stop there.
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I probably would just start with those two myself personally
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without collaboration with a colleague or my supervisor,
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unless it was an under guidance of an endocrinologist
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who said who would say, like, if the patient couldn't get into
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an endocrinologist in a reasonable amount of time,
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I might do a cold call or a little email and say, you know what?
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Would you recommend X, Y and Z tests?
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And then they would give their advisement.
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So so that's pretty much it.
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That's the kind of quick and dirty about hyperaldosteronism
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as a potential cause of resistant hypertension.
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And if you want to learn more about hypertension,
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medication and management inside of the chronic care course
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that's coming out brand new this fall, head over to realworldnp.com
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slash courses and you can get on the wait list and be the first to know
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when there's more information available and when the course is open for enrollment.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends
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Take care and talk soon.
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