Development of a Prediction Score to Avoid Confirmatory Testing in Patients With Suspected Primary Aldosteronism

Abstract

Context The diagnostic work-up of primary aldosteronism (PA) includes screening and confirmation steps. Case confirmation is time-consuming, expensive, and there is no consensus on tests and thresholds to be used. Diagnostic algorithms to avoid confirmatory testing may be useful for the management of patients with PA. Objective Development and validation of diagnostic models to confirm or exclude PA diagnosis in patients with a positive screening test. Design, Patients and Setting We evaluated 1,024 patients who underwent confirmatory testing for PA. The diagnostic models were developed in a training cohort (n=522), and then tested on an internal validation cohort (n=174) and on an independent external prospective cohort (n=328). Main outcome measure Different diagnostic models and a 16-point score were developed by machine learning and regression analysis to discriminate patients with a confirmed diagnosis of PA. Results Male sex, antihypertensive medication, plasma renin activity, aldosterone, potassium levels and presence of organ damage were associated with a confirmed diagnosis of PA. Machine learning based models displayed an accuracy of 72.9-83.9%. The Primary Aldosteronism Confirmatory Testing (PACT) score correctly classified 84.1% at training and 83.9% or 81.1% at internal and external validation, respectively. A flow chart employing the PACT score to select patients for confirmatory testing, correctly managed all patients, and resulted in a 22.8% reduction in the number of confirmatory tests. Conclusions The integration of diagnostic modelling algorithms in clinical practice may improve the management of patients with PA by circumventing unnecessary confirmatory testing.

Adrenal Venous Sampling Could Be Omitted before Surgery in Patients with Conn’s Adenoma Confirmed by Computed Tomography and Higher Normal Aldosterone Concentration after Saline Infusion Test

“…Considering the limitations of AVS, it would be most helpful to identify patients with a high certainty of the diagnosis of either unilateral or bilateral PA in whom AVS could be avoided. Nevertheless, the existing clinical prediction scores vary in accuracy according to the databases, and therefore, their clinical applicability is limited [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. In this study, we aimed to develop and validate a clinical prediction score (SCORE) for classifying the PA subtype which would be potentially superior to already published prediction methods.…”

The Effect of Antihypertensive Medications on Testing for Primary Aldosteronism

“…A relatively "novel" approach of bypassing a confirmatory test and proceeding directly to AVS (Rossi et al, 2020a;Rossi et al, 2020b) also requires more data on the effect of various antihypertensive drug classes on the diagnosis of PA based on ARR measurements only. There are also ongoing attempts to develop prediction scores to avoid confirmatory testing and/or AVS (Rossi et al, 2020a;Burrello et al, 2020). If these attempts prove successful, information on the effect of hypertensive drugs in patients evaluated using such scores will be needed.…”

Elevated Myoglobin in Patients With Primary Aldosteronism: A Cross-Sectional Study

“…Patients with cardiovascular diseases (CVD) 3 months before enrollment were considered with preexisting CVD. Target organ damage is defined as the presence of left ventricular hypertrophy at echocardiography and/or microalbuminuria ( 28 ). The local ethics committee approved the protocol, and the informed consent was obtained from all the participants.…”