Primary aldosteronism: A contrarian view

Abstract

This paper provides evidence that primary aldosteronism is likely much less common than is believed by the other authors of this collection. The basis for this contrarian view is simple: there is no way to know the true prevalence of PA because of the uncertain validity of all of the diagnostic procedures used to find and characterize this disease. Moreover, even if these uncertainties are overcome, the eventual treatment of most who have PA can be provided without the need for extensive testing and expensive treatment.

Increasing Incidence of Primary Aldosteronism in Patients Investigated for Resistant Hypertension: An Observational Study from a Nephrology Unit

“…However, today the uselfuness of ARR is still debated because there are some doubts on its reliability, in terms of reproducibility, sensitivity and specificity. Moreover, several factors could influence ARR, like the posture, the time of the day of blood sampling and the possibile use of antihypertensive drugs [1,[31][32][33]. Also, there is a lack of consensus on the types of patients' populations in which the ARR should be used as screening test for PA and on clear cut-off values to adopt.…”

Primary aldosteronism

“…As the leading investigator, Rossi [15] states in a recent review that 'in essence, the ARR is a crude bivariate analysis of variables that have a skewed distribution'. As a consequence, the level of abnormality taken as a positive test varies from 20 to as high as 69 in various publications [5].…”

“…Over the past 20 years, multiple reports based on the presence of an elevated ARR have been made, that primary aldosteronism is present in as many as 39% of hypertensive patients, the higher figures mostly coming from series of patients with resistant hypertension [5]. In the 2008 Endocrine Society Clinical Practice Guideline, the overall prevalence of primary aldosteronism was given as 6.1% of all hypertensive patients, although it states that 'studies report primary aldosteronism in more than 10% of hypertensive patients, both in general and specialty settings' [6].…”

Primary Aldosteronism

“…Therefore, some experts maintain that PA is a rare finding in the general hypertensive population. 19 In a 2012-2013 study of 296 hypertensive subjects in a New York City general internal medicine clinic population, only 4.7% screened positive for PA. Further, those who screened positive for PA were more likely to have resistant hypertension and required more antihypertensive agents for blood pressure treatment (both statistically significant). The participation of these subjects with subsequent confirmatory testing was poor, with only 6 completing confirmatory testing and, of these, only 2 testing positive for PA, an overall prevalence of only 0.67% (Galati, 2013).…”