Among 18,766 hypertensive patients tested in Taiwan, 36% met the 2025 diagnostic criteria for primary aldosteronism (PA), a hormonal condition where excess aldosterone drives resistant high blood pressure. Key risk factors included older age, female sex, low potassium levels, and requiring multiple blood pressure medications. Patients with the lowest renin levels showed the highest probability of PA diagnosis. Despite this high prevalence, a concerning treatment gap emerged: only 39% of diagnosed patients received appropriate aldosterone-targeted therapy, with just 28% getting mineralocorticoid receptor antagonist medications and 9% undergoing corrective adrenalectomy surgery. This represents a major missed opportunity for cardiovascular protection, as untreated PA significantly increases risks of heart attack, stroke, and kidney disease compared to typical hypertension. The findings suggest that simplified diagnostic criteria may identify more patients, but healthcare systems lack effective pathways to translate diagnosis into treatment. As a preprint awaiting peer review, these results require validation, but they highlight an urgent need for standardized treatment protocols to bridge the gap between PA recognition and therapeutic intervention in routine clinical practice.