Hyperaldosteronism
Background
Hyperaldosteronism refers to a condition of excess aldosterone secretion, typically leading to sodium retention, potassium excretion, and metabolic alkalosis. It is categorized into:
- Primary hyperaldosteronism (Conn syndrome) – autonomous overproduction of aldosterone, most commonly from an adrenal adenoma or bilateral adrenal hyperplasia.
- Secondary hyperaldosteronism – due to increased renin from conditions like renal artery stenosis, heart failure, or cirrhosis.
Primary hyperaldosteronism is an important and potentially reversible cause of secondary hypertension, accounting for 5–10% of hypertensive cases and up to 20% of treatment-resistant hypertension. It is often underdiagnosed in emergency settings.
Clinical Features
- Hypertension (often severe or resistant)
- Hypokalemia, which may manifest as:
- Weakness
- Fatigue
- Muscle cramps
- Constipation
- Paresthesia
- Polyuria and polydipsia
- Metabolic alkalosis (less commonly symptomatic)
- Headache or nonspecific complaints
- Asymptomatic in some patients
Differential Diagnosis
- Essential hypertension
- Cushing’s syndrome
- Pheochromocytoma
- Renal artery stenosis
- Diuretic or laxative use
- Liddle syndrome
- Bartter/Gitelman syndromes
- Chronic licorice ingestion
Evaluation
Workup
Consider hyperaldosteronism in ED patients with:
- Severe or refractory hypertension
- Unexplained hypokalemia
- Metabolic alkalosis
Recommended ED labs:
- Electrolytes (noting hypokalemia and alkalosis)
- Creatinine/BUN
- ECG (look for U waves, flattened T waves, arrhythmias)
- ABG or venous blood gas (if alkalosis suspected)
- Urine potassium (if available)
Diagnosis
Clinical suspicion in setting of hypertension + hypokalemia
Confirmatory outpatient testing with PAC/PRA ratio
Further endocrinology-guided evaluation determines surgical vs. medical management
Management
In the Emergency Department:
- Correct hypokalemia (PO or IV potassium)
- Avoid ACE inhibitors/ARBs until potassium is corrected
- Manage hypertension per usual protocols (IV meds if emergent)
- Initiate cardiac monitoring if K⁺ <3.0 mEq/L or if arrhythmia is present
Disposition
Admit if:
- Hypertensive emergency or end-organ damage
- Life-threatening hypokalemia or arrhythmia
- Severe electrolyte derangements
Discharge with outpatient follow-up if:
- Mild symptoms, stable vitals
- Newly discovered hypokalemia with controlled BP
- Reliable follow-up for endocrine evaluation