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For many years primary aldosteronism was considered a relatively benign form of hypertension. This assumption reflects the primacy accorded to elevated levels of angiotensin in terms of deleterious cardiovascular effects, and the fact that in primary aldosteronism renin and angiotensin levels are low. We now know that primary aldosteronism causes a constellation of cardiovascular, renal and metabolic sequelae which make it far from benign and that these are not merely effects of blood pressure elevation. In primary aldosteronism, tissue damage, on several indices, is higher than in age-, sex- and blood pressure-matched controls, reflecting the ability of inappropriately elevated aldosterone for salt status to produce structural and functional changes over and above those produced by high blood pressure.