A nationwide analysis of 254,338 patients with resistant hypertension revealed that only 2% received testing for primary aldosteronism (PA), a condition where excess aldosterone hormone drives blood pressure elevation. Among those diagnosed with PA, adrenalectomy reduced major cardiovascular events by 45% and death by 48% compared to medication alone, while mineralocorticoid receptor antagonist therapy cut cardiovascular events by 40%. This finding illuminates a critical gap in hypertension care, as primary aldosteronism affects an estimated 5-15% of hypertensive patients yet remains severely underdiagnosed. The superior outcomes with surgical intervention suggest that removing aldosterone-producing adrenal adenomas may offer more complete hormonal correction than medical blockade alone. However, this observational study cannot definitively establish causation, and selection bias may favor healthier patients for surgery. The dramatic underutesting represents a missed opportunity for targeted treatment in thousands of patients whose 'resistant' hypertension may actually stem from a treatable hormonal cause. As a preprint awaiting peer review, these results require validation, but they underscore the potential for precision medicine approaches in cardiovascular care.