Primary Aldosteronism Surgery Outcomes Under Current Blood Pressure Guidelines

Objective: Historical studies report complete clinical success rates of 37% following adrenalectomy for primary aldosteronism (PA), based on the former blood pressure (BP) threshold of <140/90 mmHg. This study evaluated outcomes using the current guideline BP threshold of <130/80 mmHg. Methods: We conducted a retrospective cohort study using the Epic COSMOS database of 1320 adults who underwent adrenalectomy for PA (2013-2024). Inclusion criteria included preoperative plasma aldosterone measurement and ambulatory BP measurements within 6 months and 6-18 months post-adrenalectomy. After excluding patients who had pre-adrenalectomy BP < 130/80 mmHg without antihypertensive therapy, 1079 patients were analyzed. Results: Complete clinical success (BP < 130/80 mmHg without medications post-adrenalectomy) occurred in 16.5% (178/1079; 95% CI: 14.3-18.7). Partial clinical success (improved BP control and/or reduced medications post-adrenalectomy) was achieved by 73.5% (793/1079; 95% CI: 70.9-76.1). Absent clinical success occurred in 10% (108/1079; 95% CI: 8.2-11.8). The combined rate of complete and partial clinical success was 90% (971/1079; 95% CI: 88.2-91.8). Multivariable logistic regression identified significant predictors of absence of complete clinical success: more preoperative antihypertensive medications (P < .001), higher social vulnerability (P = .02), and higher baseline systolic (P = .01) and diastolic BP (P = .003). Age, gender, race, body mass index, stroke history, sleep apnea, pre-adrenalectomy serum potassium, and estimated glomerular filtration rate were not significantly associated with outcomes. Conclusion: When applying current BP guidelines, 90% of patients achieve complete or partial clinical success after adrenalectomy for PA, demonstrating meaningful clinical outcomes. However, complete clinical success occurs in fewer patients (16.5%) than previously reported under traditional thresholds.