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Bilateral PA Medical Treatment — EECC MCQ

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ModerateHypertension & Preventive CardiologyBilateral PA Medical TreatmentEECC

A 55-year-old man with hypertension has a CT abdomen for unrelated reasons showing bilateral adrenal thickening. His plasma aldosterone is elevated and renin is suppressed. ARR is markedly elevated. CT shows bilateral adrenal hyperplasia. Adrenal vein sampling (AVS) confirms bilateral aldosterone excess. What is the treatment?

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Correct answer: E — Medical therapy with a mineralocorticoid receptor antagonist (spironolactone or eplerenone) is recommended for bilateral primary aldosteronism (bilateral adrenal hyperplasia) — surgery is reserved for unilateral disease (aldosterone-producing adenoma)

Primary aldosteronism subtype determines treatment: (1) UNILATERAL aldosterone-producing adenoma (APA): laparoscopic adrenalectomy is curative (BP normalises in 40-60%, improves in >90%); (2) BILATERAL adrenal hyperplasia (BAH): medical therapy with MRA (spironolactone 25-50 mg, or eplerenone if gynaecomastia) — surgery is NOT appropriate as removing one adrenal would not address the bilateral problem. AVS is the gold standard for lateralisation (distinguishing unilateral from bilateral disease) — CT alone is insufficient because: (1) non-functioning adrenal incidentalomas are common (3-5% of CT scans) and may coexist with PA; (2) aldosterone-producing adenomas may be too small for CT detection (<1 cm); (3) bilateral macronodular hyperplasia may mimic bilateral adenomas. The 2024 ESC Hypertension Guidelines recommend AVS before surgical decision-making.

Reference: ESC (2024): Hypertension Guidelines; Endocrine Society PA Guidelines