Personalized Treatment of Patients With Primary Aldosteronism

Obeid, Hiba; Cardenas, Stanley M Chen; Khairi, Shafaq; Turcu, Adina F.

doi:10.1016/j.eprac.2022.10.008

Cited by 4 publications

(6 citation statements)

References 99 publications

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“…Moreover, patients with cardiovascular disorders might already be taking a mineralocorticoid receptor antagonist and/or might be poor surgical candidates, which could deter from PA screening. Nevertheless, because targeted therapy for PA is associated with improved blood pressure control in these populations and mitigated kidney function decline and cardiovascular events, efforts should be made to diagnose PA even after complex comorbidities have occurred.…”

Section: Discussionmentioning

confidence: 99%

“…Compared with equivalent primary hypertension, PA has been associated with a disproportionately higher risk of cardiovascular morbidity and mortality, mediated by inappropriate mineralocorticoid receptors activation in target organs . Unilateral PA is surgically curable, and mineralocorticoid receptor antagonists (spironolactone or eplerenone) are highly effective for hypertension and hypokalemia control in nonsurgical cases . Moreover, directed PA therapy can mitigate the excessive cardiovascular and kidney complications in these patients …”

Section: Introductionmentioning

confidence: 99%

“…[12][13][14] Unilateral PA is surgically curable, 15 and mineralocorticoid receptor antagonists (spironolactone or eplerenone) are highly effective for hypertension and hypokalemia control in nonsurgical cases. 2,[16][17][18][19][20][21] Moreover, directed PA therapy can mitigate the excessive cardiovascular and kidney complications in these patients. [22][23][24][25][26][27] Expert guidelines recommend PA screening for at-risk patients, including those with apparent treatment-resistant hypertension (uncontrolled blood pressure despite the concurrent use of 3 antihypertensive drug classes, including diuretics, or controlled blood pressure while taking ≥4 antihypertensive medications), 28 hypertension and hypokalemia, incidentally found adrenal nodule(s), obstructive sleep apnea (OSA), and/or a family history of early-onset hypertension or stroke.…”

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confidence: 99%

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Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Charoensri,

Bashaw,

Dehmlow

et al. 2024

JAMA Intern Med

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ImportancePrimary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA.ObjectiveTo develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening.Design, Setting, and ParticipantsThis prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded.ExposureA noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance.Main Outcomes and Measures(1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed.ResultsOver 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications.Conclusions and RelevanceThe study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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confidence: 99%

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Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Charoensri,

Bashaw,

Dehmlow

et al. 2024

JAMA Intern Med

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“…Lastly, hyperaldosteronism in the elderly responds well to MRA, with fewer side effects compared to the young. Spironolactone is still the most prevalent MRA in use, and given its high percentage of hormonal in uences, older males can probably tolerate spironolactone better than younger patients [32]. Surprisingly, despite low screening rates for APA in the elderly, only a small fraction of these patients with rHTN are empirically treated with an MRA [36], either due to fear of side effects, or a more lenient approach for higher BP values in the elderly.…”

Section: Discussionmentioning

confidence: 99%

Unsatisfactory screening rates for Primary Aldosteronism in high risk patients

Korman,

Rapoport,

German

et al. 2024

Preprint

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The Endocrine Society (ES) guidelines recommend screening for primary aldosteronism (PA) in high risk hypertensive patients presenting with at least one of seven criteria (resistant HTN, hypokalemia, adrenal nodule etc.). Although guidelines are clear and screening is simple, compliance rates among clinicians are extremely low. This results in underdiagnosis of early disease, leading to cadiovasculaer complications and extra-burden of advanced chronic kidney disease. We aimed to evaluate the screening rates in the Nephrology and Hypertension clinics at Assuta Ashdod University Hospital, Israel. Data on adult hypertensive patients was retrieved during January 2018 to December 2020. Included in the study were hypertensive patients who had at least one of the ES criteria for PA screening. Of all suitable patients, we compared those who were screened for PA to patients who were not screened. Univariate and multivariate cox regression analysis were used for comparison between groups. Of 661 patients with HTN, 218 patients (33%) met the ES guidelines for PA screening. Forty-six of them (21.1%), were referred for screening. Advanced age and male gender were associated with lower screening referral rates. Odds ratio for age was 0.945 for every year (95% CI 0.915-0.975). There was a trend towards decreased referral rate in advanced kidney disease. A 21% screening rate, suggests that many cases of PA are likely missed, more often in older patients.We therefore advocate for PA screening of all hypertensive patients, especially elderly patients with CKD, in whom clinicians’ awareness is low but the absolute risk is high.

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“…Personalized therapy of PA therapy takes into account 2 broad subtypes: unilateral PA, commonly attributed to surgically curable aldosterone-producing adenomas (APA), and bilateral PA, treated with mineralocorticoid receptor antagonists. 14 Overall, unilateral adrenalectomy is considered more effective in improving blood pressure control, 15 and in reducing the risk of incident cardiovascular events, 13 atrial fibrillation, 8 and renal insufficiency 7 than medical therapy for PA.…”

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confidence: 99%

Multifocal, Asymmetric Bilateral Primary Aldosteronism Cannot be Excluded by Strong Adrenal Vein Sampling Lateralization: An International Retrospective Cohort Study

Turcu,

Tezuka,

Lim

et al. 2024

Hypertension

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BACKGROUND: Primary aldosteronism (PA) has been broadly dichotomized into unilateral and bilateral forms. Adrenal vein sampling (AVS) lateralization indices (LI) ≥2 to 4 are the standard-of-care to recommend unilateral adrenalectomy for presumed unilateral PA. We aimed to assess the rates and characteristics of residual PA after AVS-guided adrenalectomy. METHODS: We conducted an international, retrospective, cohort study of patients with PA from 7 referral centers who underwent unilateral adrenalectomy based on LI≥4 on baseline and/or cosyntropin-stimulated AVS. Aldosterone synthase (CYP11B2) immunohistochemistry and next generation sequencing were performed on available formalin-fixed paraffin-embedded adrenal tissue. RESULTS: The cohort included 283 patients who underwent AVS-guided adrenalectomy, followed for a median of 326 days postoperatively. Lack of PA cure was observed in 16% of consecutive patients, and in 22 patients with lateralized PA on both baseline and cosyntropin-stimulated AVS. Among patients with residual PA postoperatively, 73% had multiple CYP11B2 positive areas within the resected adrenal tissue (versus 23% in those cured), wherein CACNA1D mutations were most prevalent (63% versus 33% in those cured). In adjusted regression models, independent predictors of postoperative residual PA included Black versus White race (odds ratio, 5.10 [95% CI, 1.45–17.86]), AVS lateralization only at baseline (odds ratio, 8.93 [95% CI 3.00–26.32] versus both at baseline and after cosyntropin stimulation), and CT-AVS disagreement (odds ratio, 2.75 [95% CI, 1.20–6.31]). CONCLUSIONS: Multifocal, asymmetrical bilateral PA is relatively common, and it cannot be excluded by robust AVS lateralization. Long-term postoperative monitoring should be routinely pursued, to identify residual PA and afford timely initiation of targeted medical therapy.

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Personalized Treatment of Patients With Primary Aldosteronism

Cited by 4 publications

References 99 publications

Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

Unsatisfactory screening rates for Primary Aldosteronism in high risk patients

Multifocal, Asymmetric Bilateral Primary Aldosteronism Cannot be Excluded by Strong Adrenal Vein Sampling Lateralization: An International Retrospective Cohort Study

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