Adrenalectomy Linked to Lower Medication Burden Below Usual Aldosteronism Lateralization Threshold

An adrenal vein sampling lateralization index (LI) ≥4 commonly distinguishes unilateral primary aldosteronism managed surgically from bilateral disease managed medically. A retrospective cohort study in the Journal of the American College of Surgeons examined 491 patients undergoing sampling during 2002–2022. Groups comprised 101 patients with LI<4 managed without adrenalectomy, 367 with LI≥4 undergoing adrenalectomy, and 23 with LI<4 undergoing adrenalectomy. Outcomes were systolic blood pressure and antihypertensive medication count at 6–12 months.

Patients undergoing surgery with LI<4 were younger and more frequently male than those in the other groups; baseline systolic blood pressure and hypertension duration did not differ. After inverse probability treatment weighting, surgery in the LI<4 group was associated with a greater medication reduction than medical management: an adjusted difference of −0.88 medications (95% CI −1.64 to −0.13; p=0.022). There was no significant difference in systolic blood pressure. Propensity score matching supported these findings.

The results support considering individual clinical circumstances rather than using LI≥4 as an absolute surgical threshold. However, the retrospective design, baseline group differences, and small below-threshold surgical subgroup limit causal interpretation. The observed benefit concerned medication burden over 6–12 months, not demonstrated superiority in blood pressure control or long-term clinical outcomes.