Algorithm for the detection, confirmation, subtype testing, and treatment of PA.

^a We recommend unilateral laparoscopic adrenalectomy for patients with documented unilateral PA (ie, APA or UAH) (1∣⊕⊕⊕○). If a patient is unable or unwilling to undergo surgery, we recommend medical treatment including a MR antagonist (1∣⊕⊕⊕○). If an ARR-positive patient is unwilling or unable to undergo further investigations, we similarly recommend medical treatment including an MR antagonist (1∣⊕⊕○○). ^b Instead of proceeding directly to subtype classification, we recommend that patients with a positive ARR undergo one or more confirmatory tests to definitively confirm or exclude the diagnosis (1∣⊕⊕○○). However, in the setting of spontaneous hypokalemia, undetectable renin, and PAC >20 ng/dL (550 pmol/L), we suggest that there may be no need for further confirmatory testing (2∣⊕○○○). ^c We recommend that when surgical treatment is feasible and desired by the patient, an experienced radiologist should use AVS to make the distinction between unilateral and bilateral adrenal disease (1∣⊕⊕⊕○). Younger patients (<age 35) with spontaneous hypokalemia, marked aldosterone excess, and unilateral adrenal lesions with radiological features consistent with a cortical adenoma on adrenal CT scan may not need AVS before proceeding to unilateral adrenalectomy (2∣⊕○○○). [Adapted from J. W. Funder et al: Case detection, diagnosis, and treatment of patients with primary aldosteronism: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2008;93:3266–3281 (3), with permission. © Endocrine Society.]