Surgical Versus Medical Treatment of Primary Aldosteronism: Comparative Effects on Long-Term Blood Pressure Outcomes From a Meta-Analytic Perspective

Objective: Primary aldosteronism (PA) is the most prevalent and potentially curable cause of secondary hypertension and is associated with disproportionate cardiovascular morbidity driven by sustained blood pressure (BP) elevation and aldosterone-mediated target-organ damage. Although unilateral adrenalectomy and medical therapy with mineralocorticoid receptor antagonists (MRAs) are both established treatments, their long-term comparative effectiveness on BP reduction remains incompletely defined. We performed a systematic review and meta-analysis to assess whether adrenalectomy provides superior long-term BP improvement compared with MRA therapy in PA. Design and method: MEDLINE and Embase were systematically searched for prospective and retrospective clinical studies published up to September 2025. Eligible studies included adults with confirmed PA treated with adrenalectomy or MRAs and reporting changes in office and/or ambulatory systolic and diastolic BP from baseline, with a minimum follow-up of 6 months. Data extraction and risk-of-bias assessment were independently performed by two reviewers using standardized instruments. Pooled estimates were calculated using fixed- and random-effects models. The primary outcome was the mean difference in office systolic BP (SBP) change; secondary outcomes included office diastolic BP (DBP) and ambulatory BP changes. Results: Thirty-eight studies encompassing 11,253 patients (47% adrenalectomy; 53% MRA therapy) were included; 35 of them at low risk of bias. From comparable baseline BP values, both treatment strategies achieved substantial BP reductions over a median follow-up of 12 months (IQR 12-29). However, adrenalectomy was associated with a significantly greater reduction in office SBP (mean difference -4.37 mmHg; 95% CI -5.32 to -3.41; P<0.0001) and DBP (-1.60 mmHg; 95% CI -2.24 to -0.95; P<0.0001) compared with MRA therapy, without relevant heterogeneity or publication bias. Multivariate meta-regression identified baseline DBP and SBP as significant effect modifiers of SBP response following surgical and medical treatment, respectively. In seven studies reporting ambulatory BP, no between-group differences were observed. Conclusions: Adrenalectomy achieves superior long-term office BP reduction compared with medical therapy in PA. These findings reinforce adrenalectomy as the preferred strategy for unilateral PA and highlight the need for future comparative studies incorporating optimized medical regimens, including nonsteroidal MRAs and aldosterone synthase inhibitors, to further refine BP and cardiovascular risk management.