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.

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.