Confirmed Unilateral Primary Aldosteronism in a Surgery-Reluctant Patient
A single patient whose adrenal vein sampling confirms exactly the finding surgery cures best, set against his own repeated, informed refusal of that surgery.
Roland K., a 52-year-old commercial diver, has spent his career underwater on offshore rigs and is, by his own account, more afraid of a hospital bed than he has ever been of depth or current. He keeps a small dry-erase board on his refrigerator with a running count of days left until his next rotation offshore, and has told his endocrinologist plainly that losing weeks to a recovery he doesn't think he needs is not a trade he's willing to make. His resistant hypertension led to a primary aldosteronism workup two months ago, and adrenal vein sampling — genuinely difficult in his case given tortuous venous anatomy the interventional radiologist noted took three attempts to catheterize — confirmed clear unilateral lateralization to a left adrenal adenoma. Laparoscopic adrenalectomy is the guideline-recommended treatment for exactly this finding, and would very likely cure or substantially improve his hypertension without lifelong medication. Roland has said plainly, twice now, that he does not want surgery, citing a bad outcome his brother had from an unrelated operation and his own reluctance to be out of the field for the recovery period his job would require.
What makes his reluctance a harder problem than a straightforward informed-refusal conversation is that the evidence behind adrenalectomy in confirmed unilateral disease isn't only about blood pressure control, which medical therapy can often approximate. Hundemer et al. found that patients with primary aldosteronism managed medically, even with blood pressure similarly controlled to surgically treated patients, carry higher rates of new-onset atrial fibrillation, diabetes, and cardiovascular events — attributed to aldosterone's direct fibrotic effects on the heart and vasculature, independent of blood pressure itself. That distinction is exactly what makes "his blood pressure would probably be fine on spironolactone" an incomplete answer to what he's actually asking.
Endocrinology follow-up, after adrenal vein sampling
He's told us twice, clearly, that he doesn't want surgery, and given us real reasons — his brother's outcome, his job. I don't think our job is to keep making the case for adrenalectomy past a decision he's already made competently. Let's optimize spironolactone and manage him medically, the way he's asked us to.
I respect that this is his decision — I'm not proposing we override it. But I want to make sure the decision he's making is actually informed by the full picture, not just blood pressure numbers. He already has mild LVH, and in Hundemer's cohorts patients managed medically for confirmed unilateral disease carried higher rates of new-onset atrial fibrillation and further cardiac remodeling than surgically treated patients, even when blood pressure control looks similar. That's a distinct risk from "will spironolactone control his numbers," and I don't think he's heard that framing yet.
The part I'd concede is different from the part you're defending. He has been told the truth about his blood pressure, and he has decided about his blood pressure. He has not yet been told that spironolactone and adrenalectomy may not carry the same atrial fibrillation risk even when the numbers on the cuff match. He hasn't refused that conversation. He hasn't had it.
Then let's do both — start him on high-dose spironolactone today, since that's what he's asked for, and build a real monitoring plan around exactly the risk the endocrinologist is raising: repeat echocardiogram in six months, ongoing rhythm monitoring given his LVH, and a structured re-conversation about surgery at that point with whatever new information those tests give us. That way his decision stays genuinely informed as we go, rather than either overriding him today or dropping the subject entirely.
Agreed: start high-dose spironolactone per Roland's stated preference, with a structured six-month re-evaluation including echocardiography and rhythm monitoring, and an explicit re-conversation about surgery once those results are in.
Not agreed: what should happen if his LVH progresses despite adequately controlled blood pressure and potassium on medical therapy. The endocrinologist would treat that as strong grounds to press the surgical recommendation more firmly; the primary care physician remains committed to his autonomy regardless of what the monitoring shows, provided he continues to make an informed choice.