Evolution of diagnostic criteria for primary aldosteronism: why is it more common in "drug-resistant" hypertension today?

The recent "epidemic" of primary aldosteronism reported in the literature is most likely related to the widespread acceptance that with easy access to accurate measurements of renin and aldosterone, it is no longer necessary to wait until hypokalemia has become profound before embarking on diagnostic testing to attempt to ferret out this most common cause of "essential" hypertension. This is especially true for those who are now classified as "drug resistant" using today's popular drugs, which are particularly ineffective in lowering blood pressure in primary aldosteronism and its variants. Understanding the physiologic consequences of a slowly increasing aldosterone production by autonomous cells will help both the family practitioner and the specialist understand the role of the aldosterone renin ratio (ARR) in the care of the hypertensive patient. In addition, the increasing number of specific genetic mutations that drive sodium retention and lead to low levels of renin activity and familial hypertension must be incorporated into the routine evaluation and care of hypertensive patients and their families.