Do you forgo adrenal imaging in a patient with primary hyperaldosteronism who has decided against surgery?

Yes. It would be a waste of time and money. Can go straight to using spironolactone or other mineralocorticoid blocker.

I agree with the new Endocrine Society guidelines on pursuing adrenal imaging if AVS and surgery are planned. In my opinion, the yield of finding a significant adrenal pathology that will change management in a patient with suspected PA who does not desire surgery is extremely low.

Starting ALDOSTERONE blocker would be prudent in such cases and save money on imaging.