Primary aldosteronism is the most common form of secondary hypertension. Recent evidence indicates that aldosterone excess occurs on a clinically relevant spectrum, detectable in mild hypertension and even normotension. Globally, the aldosterone-renin ratio is the recommended initial screening test but has limitations in sensitivity and reliability with single measurements. Screening populations vary across international guidelines and consensus statements, ranging from only high-risk hypertensive patients to broader screening for all patients with hypertension. The rationale for universal screening is for earlier identification of primary aldosteronism and to mitigate the long-term risks associated with the disease when left untreated, including cardiovascular and renal complications. Patients with unilateral disease benefit from adrenalectomy to potentially cure hypertension and reverse end-organ damage, while those with bilateral disease likely benefit from appropriate treatment with mineralocorticoid antagonists. However, clinical outcomes and cost-effectiveness of universal screening remain undetermined.