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PubMed This is a summary of 17 peer-reviewed journal articles Updated
Cardiology · Primary Aldosteronism

Recognizing the Symptoms and Warning Signs

At a Glance

The most common symptom of primary aldosteronism is resistant hypertension, meaning blood pressure stays high despite taking multiple medications. Unlike older medical beliefs, up to 90% of people with this condition have normal potassium levels, so it can easily go unnoticed.

Many people believe that Primary Aldosteronism (PA) has obvious, dramatic symptoms. In reality, PA is often a “silent” driver of damage that can be easily mistaken for standard high blood pressure. Because the excess hormone aldosterone affects the entire body, the symptoms are often systemic, affecting the heart, muscles, and even your sleep [1][2].

The Most Common Sign: Resistant Hypertension

The hallmark of PA is high blood pressure that is difficult to manage. You may have resistant hypertension, which is defined as blood pressure that remains above target even though you are taking three or more different types of medications [1]. In some cases, PA may even be present in people with “pre-hypertension” or mild high blood pressure before it becomes severe [3].

The Potassium Myth: Why Diagnoses are Missed

Historically, doctors were taught that the main sign of PA was hypokalemia (low potassium) [4]. However, modern research has flipped this understanding:

  • Normokalemia (Normal Potassium): The vast majority of people with PA—as many as 60% to 90%—actually have normal potassium levels [5][6].
  • The Risk: If a doctor only screens for PA when potassium is low, most cases will be missed [4][7].

If your potassium is low, you may experience “obvious” symptoms like muscle cramps, weakness, or fatigue [1]. But even if your potassium is normal, the excess aldosterone is still active in your body.

Systemic and “Hidden” Warning Signs

Beyond high blood pressure, PA can cause several other conditions that serve as warning signs:

  • Heart Rhythm Issues: People with PA have a much higher risk of developing atrial fibrillation (AFib), an irregular and often rapid heart rate that can lead to blood clots or stroke [8][9].
  • Sleep Apnea: There is a strong link between PA and obstructive sleep apnea (OSA), a condition where you repeatedly stop and start breathing during sleep [10][11].
  • Frequent Nighttime Urination: Also known as nocturia, many patients find they must wake up multiple times during the night to urinate [10].
  • Heart Thickening: Excess aldosterone causes the heart to work harder and can lead to left ventricular hypertrophy (LVH), a thickening of the heart’s main pumping chamber [12][13].

Why PA is Different from “Normal” High Blood Pressure

In “essential” (standard) hypertension, the damage to your body is mostly caused by the physical pressure of the blood against your artery walls. In PA, the damage is two-fold:

  1. High Pressure: The high blood pressure itself causes wear and tear.
  2. Hormonal Damage: Excess aldosterone is “toxic” to your organs. It directly causes inflammation and scarring (fibrosis) in the heart, kidneys, and blood vessels [13][14].

This means that a person with PA is at a higher risk for stroke, heart attack, and kidney failure than someone with standard high blood pressure, even if their blood pressure numbers are exactly the same [15][16]. Identifying these warning signs early is the first step toward getting treatment that stops this hormonal damage [17].

Common questions in this guide

What is the most common symptom of primary aldosteronism?
The hallmark sign of primary aldosteronism is resistant hypertension. This means your blood pressure remains consistently high even if you are actively taking three or more different types of blood pressure medications.
Can I have primary aldosteronism if my potassium is normal?
Yes. While doctors used to believe low potassium was the main sign, modern research shows that up to 90 percent of people with primary aldosteronism have normal potassium levels. Normal potassium should not stop you from being screened.
How does primary aldosteronism affect the heart?
Excess aldosterone is toxic to your organs and causes the heart to work harder. This can lead to left ventricular hypertrophy (a thickening of the heart muscle) and increases your risk of developing atrial fibrillation, an irregular heart rhythm.
Why is primary aldosteronism more dangerous than standard high blood pressure?
Standard high blood pressure damages your body through physical pressure against artery walls. Primary aldosteronism causes that same pressure damage, but the excess aldosterone also directly causes inflammation and scarring in the heart, kidneys, and blood vessels.
Is sleep apnea linked to high aldosterone levels?
Yes, there is a strong link between primary aldosteronism and obstructive sleep apnea. Many patients with high aldosterone levels experience interrupted breathing during sleep and frequent nighttime urination.

Questions to Ask Your Doctor

Curated prompts to bring to your next appointment.

  1. 1.Is my high blood pressure considered 'resistant,' and does that mean I should be screened for primary aldosteronism?
  2. 2.I've read that most people with this condition have normal potassium levels. Can we check my aldosterone-to-renin ratio even if my potassium is normal?
  3. 3.Are my heart palpitations or irregular heartbeat potentially linked to my aldosterone levels?
  4. 4.Should I be screened for obstructive sleep apnea as well, given my high blood pressure?
  5. 5.Has my high blood pressure caused any thickening of my heart muscle (left ventricular hypertrophy)?

Questions For You

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References

References (17)
  1. 1

    Prevalence of primary aldosteronism and screening indications.

    Ruiz-Sanchez JG

    Vitamins and hormones 2026; (130()):43-67 doi:10.1016/bs.vh.2025.08.001.

    PMID: 41638804
  2. 2

    Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis.

    Monticone S, D'Ascenzo F, Moretti C, et al.

    The lancet. Diabetes & endocrinology 2018; (6(1)):41-50 doi:10.1016/S2213-8587(17)30319-4.

    PMID: 29129575
  3. 3

    Cerebro-Cardiovascular Risk, Target Organ Damage, and Treatment Outcomes in Primary Aldosteronism.

    Lin X, Ullah MHE, Wu X, et al.

    Frontiers in cardiovascular medicine 2021; (8()):798364 doi:10.3389/fcvm.2021.798364.

    PMID: 35187110
  4. 4

    Screening for primary aldosteronism is underutilised in patients with chronic kidney disease.

    Chauhan K, Schachna E, Libianto R, et al.

    Journal of nephrology 2022; (35(6)):1667-1677 doi:10.1007/s40620-022-01267-3.

    PMID: 35195879
  5. 5

    Update on Primary Aldosteronism: Time to Screen All Hypertensives.

    Memon SS, Bandgar T

    The Journal of the Association of Physicians of India 2024; (72(1)):11-12 doi:10.59556/japi.71.0430.

    PMID: 38736067
  6. 6

    Aldosterone to Renin Ratio as a Screening Instrument for Primary Aldosteronism in a Middle-Aged Population with Atrial Fibrillation.

    Mourtzinis G, Ebrahimi A, Gustafsson H, et al.

    Hormone and metabolic research = Hormon- und Stoffwechselforschung = Hormones et metabolisme 2017; (49(11)):831-837 doi:10.1055/s-0043-119220.

    PMID: 28934817
  7. 7

    Primary aldosteronism prevalence enhanced by strict adherence to 2016 Endocrine Society guidelines: insights from an endocrine hypertension unit.

    Ruiz-Sanchez JG, Fernandez Sanchez Á, Cardenas-Salas J, et al.

    Journal of hypertension 2024; (42(10)):1813-1822 doi:10.1097/HJH.0000000000003822.

    PMID: 39196692
  8. 8

    Title not available

    Hibatouallah H, Guedira MM, Siagh S, et al.

    Annales de cardiologie et d'angeiologie 2025; (74(5)):101952 doi:10.1016/j.ancard.2025.101952.

    PMID: 40992350
  9. 9

    Atrial fibrillation as presenting sign of primary aldosteronism: results of the Prospective Appraisal on the Prevalence of Primary Aldosteronism in Hypertensive (PAPPHY) Study.

    Seccia TM, Letizia C, Muiesan ML, et al.

    Journal of hypertension 2020; (38(2)):332-339 doi:10.1097/HJH.0000000000002250.

    PMID: 31834121
  10. 10

    Screening for Primary Aldosteronism is Underutilized in Patients with Obstructive Sleep Apnea.

    Conroy PC, Hernandez S, Graves CE, et al.

    The American journal of medicine 2022; (135(1)):60-66 doi:10.1016/j.amjmed.2021.07.041.

    PMID: 34508708
  11. 11

    Prospective Screening for Primary Aldosteronism in Patients With Suspected Obstructive Sleep Apnea.

    Chee MR, Hoo J, Libianto R, et al.

    Hypertension (Dallas, Tex. : 1979) 2021; (77(6)):2094-2103 doi:10.1161/HYPERTENSIONAHA.120.16902.

    PMID: 33896193
  12. 12

    Adrenalectomy Versus Medical Therapy in Primary Aldosteronism: A Meta-Analysis of Long-Term Cardiac Remodeling and Function: Medical versus Adrenalectomy Treatment Compared in Hyperaldosteronism (MATCH) Study.

    Marzano L, Zoccatelli F, Pizzolo F, Friso S

    Hypertension (Dallas, Tex. : 1979) 2025; (82(8)):e142-e153 doi:10.1161/HYPERTENSIONAHA.125.25104.

    PMID: 40557482
  13. 13

    Cortisol Excess in Patients With Primary Aldosteronism Impacts Left Ventricular Hypertrophy.

    Adolf C, Köhler A, Franke A, et al.

    The Journal of clinical endocrinology and metabolism 2018; (103(12)):4543-4552 doi:10.1210/jc.2018-00617.

    PMID: 30113683
  14. 14

    Primary Aldosteronism: a Continuum from Normotension to Hypertension.

    Wannachalee T, Turcu AF

    Current cardiology reports 2021; (23(8)):105 doi:10.1007/s11886-021-01538-8.

    PMID: 34196827
  15. 15

    Renal damage in primary aldosteronism: a systematic review and meta-analysis.

    Monticone S, Sconfienza E, D'Ascenzo F, et al.

    Journal of hypertension 2020; (38(1)):3-12 doi:10.1097/HJH.0000000000002216.

    PMID: 31385870
  16. 16

    Prevalence and clinical characteristics of primary aldosteronism in a tertiary-care center in Korea.

    Yoon M, Hong N, Ha J, et al.

    Hypertension research : official journal of the Japanese Society of Hypertension 2022; (45(9)):1418-1429 doi:10.1038/s41440-022-00948-7.

    PMID: 35681044
  17. 17

    Reversal of arterial stiffness in medically and surgically treated unilateral primary aldosteronism.

    Chen ZW, Liao CW, Pan CT, et al.

    Journal of hypertension 2024; (42(3)):538-545 doi:10.1097/HJH.0000000000003631.

    PMID: 38088428

This page provides educational information about primary aldosteronism symptoms. It does not replace professional medical advice. Always consult your healthcare provider if you have difficult-to-manage high blood pressure.

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