Primary Aldosteronism: State-of-the-Art Review

Vaidya, Anand; Hundemer, Gregory L.; Nanba, Kazutaka; Parksook, Wasita Warachit; Brown, Jenifer M

doi:10.1093/ajh/hpac079

Cited by 45 publications

(63 citation statements)

References 308 publications

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“…On the other hand, it proved to be informative and may be valid in many cases. A shift toward more pragmatic testing for PA should be considered in light of the poor adherence to screening recommendations [ 7 ].…”

Section: Discussionmentioning

confidence: 99%

“…While the deleterious effects of overt PA are widely appreciated, AAS is currently not an established disorder; mild PA forms remain largely unrecognized [ 7 ]. Our study demonstrates a relatively high prevalence of (possible) autonomous aldosterone excess among patients with adrenocortical adenoma/hyperplasia.…”

Section: Discussionmentioning

confidence: 99%

“…The study protocol consisted of: recording patient history and physical examination, ECG, laboratory examinations, 24 h ambulatory blood pressure monitoring (ABPM), TTE, and measurement of common carotid arteries’ (CCAs) IMT. As previously reviewed, PA/AAS has been associated with HT, atherosclerosis, metabolic syndrome, and pathologic cardiac remodeling, which underlies the methodology of the study (respectively, ABPM, IMT, lipid profile, and TTE) [ 5 , 7 , 10 ].…”

Section: Methodsmentioning

confidence: 99%

“…While a fully objective assessment of Ald secretion requires therapy modification to limit the influence on the renin–angiotensin–aldosterone system (RAAS), this requirement frequently dissuades clinicians from ordering screening — research shows less than 10% of eligible patients undergo it both in primary care and specialist settings [ 6 , 7 ]. Furthermore, in overt PA, medication withdrawal is often unnecessary and not advised by some, since, in principle, a constellation of suppressed renin and unsuppressed Ald should not occur in a person with normal RAAS function, regardless of the use of interfering medications [ 7 , 8 ]. What should also be considered in the approach to possible excess aldosteronism is the selection of controls used for the determination of test cutoffs.…”

Section: Introductionmentioning

confidence: 99%

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Autonomous Aldosterone Secretion in Patients with Adrenal Incidentaloma

et al. 2022

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In recent years, research has emphasized the significance of mild clinical and biochemical presentations of primary aldosteronism (PA) that do not meet current diagnostic criteria of the syndrome. In this study, we assessed the prevalence of autonomous aldosterone (Ald) secretion (AAS), defined as a positive (>1.2 ng/dL/mIU/L) Ald-to-renin ratio (ADRR) combined with unsuppressed Ald (>4 ng/dL), and its associations with blood pressure (BP), cardiac function, and common carotid artery (CCA) intima-media thickness (IMT) in patients with incidentally discovered adrenal adenomas (AI), who were either normo- or hypertensive but had no other cardiovascular disease. Among 332 AI patients hospitalized between November 2018 and December 2019, 63 study participants were recruited (26 normo- and 37 hypertensive), who underwent hormonal examinations, 24 h ambulatory BP measurement, transthoracic echocardiography, and CCA IMT assessment without altering chronic medications. AAS was found in approximately 25% of subjects (seven normo- and nine hypertensive); urinary aldosterone excretion (UAldE) exceeded 10 ug/day in none of the subjects. The left ventricular mass index correlated positively with UAldE in non-diabetic patients (n = 50), and negatively with renin in those without beta blocker therapy (n = 38). The study shows that a pragmatic approach to hormonal assessment (no chronic therapy modification) may reveal patients with AAS. Screening for this subclinical PA presentation is probably more effective with a permissive ADRR than UAldE in such a setting.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Autonomous Aldosterone Secretion in Patients with Adrenal Incidentaloma

et al. 2022

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Adrenal ablation therapy for unilateral primary aldosteronism: pros and cons

Shibata

2022

Hypertens Res

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Primary aldosteronism (PA) is one of the most prevalent causes of endocrine hypertension [1][2][3]. A recent metaanalysis on the prevalence of PA showed that 4.3% of hypertensive patients in a primary care setting and 9.0% of referred patients had confirmed PA. Patients with PA present with high plasma aldosterone concentration, suppressed plasma renin activity or concentration, and saltsensitive hypertension. Compared to age-and sex-matched essential hypertensive patients with similar extents of hypertension, PA patients show significantly higher cerebro-and cardiovascular comorbidities [1][2][3][4]. The two most common subtypes of PA are aldosterone-producing adenoma (mostly unilateral) and bilateral adrenal hyperplasia. The former subtype shows markedly high plasma aldosterone concentration, suppressed plasma renin activity, spontaneous hypokalemia, and frequently resistant hypertension, whereas the latter subtype shows a milder clinical phenotype, including mild hypertension, normal to high plasma aldosterone concentration and normokalemia. Based on clinical practice guidelines, laparoscopic unilateral adrenalectomy is recommended for unilateral PA, whereas medical treatment with MR antagonists is recommended for bilateral PA as well as patients who do not desire surgery or are not eligible for surgery.Recently, increasing numbers of papers have been published with regard to alternative therapies for unilateral PA other than conventional unilateral laparoscopic adrenalectomy. These include CT-guided radiofrequency ablation (RFA), transvenous RFA, catheter-based adrenal ablation * Hirotaka Shibata

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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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Primary Aldosteronism: State-of-the-Art Review

Cited by 45 publications

References 308 publications

Autonomous Aldosterone Secretion in Patients with Adrenal Incidentaloma

Autonomous Aldosterone Secretion in Patients with Adrenal Incidentaloma

Adrenal ablation therapy for unilateral primary aldosteronism: pros and cons

Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening

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