Primary aldosteronism (PA) is the most common endocrine cause of hypertension that affects ~5-10% of hypertensive patients in the primary care setting. Traditionally associated with hypokalemia, serum potassium actually lies in the normal range in the majority of patients. Hence, PA is rarely identified unless tested for specifically, with aldosterone and renin levels (expressed as a ratio, the ARR). At present, the ARR is not part of the routine hypertension work-up, so PA is frequently missed. Even when screening is performed, confounding factors such as antihypertensive medications and phase of menstrual cycle can interfere with the result. Further dilemmas lie in the interpretation of confirmatory tests and adrenal vein sampling results, and optimal management of patients with unilateral or bilateral forms of the disease. These issues will be discussed in the context of perplexing clinical cases