• Sustained BP >150/100 mmHg on each of three measurements.
• Hypertension resistant to 3 conventional drugs (incl. diuretic) or controlled on ≥4 drugs.
• Hypertension with spontaneous or diuretic-induced hypokalemia.
• Hypertension with adrenal incidentaloma.
• Hypertension with sleep apnea.
• Hypertension and family history of early-onset hypertension or cerebrovascular accident <40y.
• First-degree relatives of patients with PA.

Primary aldosteronism is characterized by autonomous aldosterone production leading to suppression of renin. Hence, an elevated ratio is pathognomonic if confirmed.

• Correct hypokalemia before testing (low K inhibits aldosterone).
• Liberalize sodium intake before testing.
• Patient should be out of bed (seated or standing) for ≥2 hours.
• Draw sample mid-morning.

• Do not interpret elevated isolated ratio if PAC is unequivocally low.
• Proceed to a confirmatory testing (e.g., Saline Infusion Test, Captopril Challenge, or Oral Sodium Loading).
• If PAC is immensely elevated (>20 ng/dL) with suppressed renin and spontaneous hypokalemia, PA is confirmed without further testing.
• Adrenal protocol CT scan to assess anatomy and rule out carcinoma.