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Guideline: Primary aldosteronism ‘major public health issue’
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Many adults with hypertension do not undergo the necessary screening for primary aldosteronism, and those who do often receive suboptimal care, making the condition a “major public health issue” that needs to be addressed by physicians, according to an updated clinical practice guideline released by the Endocrine Society.
In an update of the 2008 clinical practice guideline, researchers said more patients with primary aldosteronism will benefit from demand-driven diagnosis and effective treatment, including targeted mineralocorticoid receptor antagonist therapy.
“Because case detection entails follow-up, and these procedures are expensive, the present rate of screening is very low,” John W. Funder, MD, PhD, FRACP, FRCP, senior fellow at the Hudson Institute of Medical Research and a professor in the department of medicine at Monash University, Australia, and colleagues wrote. “Therefore, most subjects with [primary aldosteronism] are never screened. Our recommendation that a sizeable percentage of those with hypertension undergo screening is, thus, not a counsel of perfection, but a clarion call to physicians to substantially ramp up the screening of hypertensive patients at risk for [primary aldosteronism].”
John W. Funder
An eight-member task force of experts from the Endocrine Society reviewed systematic analyses of aldosteronism, conducted during the past 6 years, and provided several revisions:
- Screening indications should be broadened to include patients with elevated sustained systolic blood pressure of more than 150 mm Hg and/or diastolic BP of more than 100 mm Hg.
- Less stringent cutoffs for both the aldosterone-to-renin ratio and plasma aldosterone concentration will produce a positive rate of approximately 10% in patients with hypertension, with the majority of patients having idiopathic adrenal hyperplasia as the source of autonomous aldosterone secretion.
- New evidence suggests a higher risk for cardiovascular and renal complications in patients with primary aldosteronism, including arrhythmias, myocardial infarction, stroke, chronic kidney disease and death vs. age-, sex- and BP-matched adults with hypertension; early detection can improve CV outcomes.
- Primary care physicians should refer patients with suspected primary aldosteronism to specialized centers for further testing, as well as patients with spontaneous hypokalemia, renin levels less than the detection limit plus florid hyperaldosteronism.
“We need to make screening, confirmation/exclusion/lateralization more widely available and less expensive over the next 5 to 10 years, given that primary aldosteronism has a higher cardiovascular risk profile than age-, sex-, and blood pressure-matched essential hypertension,” Funder told Endocrine Today. “Don't hold back on referring patients in whom you suspect primary aldosteronism to be a possibility. Second, if after screening the patient has a relatively high (=/> 50%) probability of PA, but cannot afford to go further in what currently may be a $30,000-plus pathway, treat the hypertension with the inclusion of a mineralocorticoid receptor antagonist.”
Funder noted that the current “cut-offs” for establishing the diagnosis of primary aldosteronism are generally stringent and preferentially pick up more florid cases; however, emerging data point to inappropriate aldosterone secretion being implicated in over 50% of hypertension.
“If this is the case — which will need additional independent studies — then first line therapy for all hypertensives might very usefully include a low dose mineralocorticoid receptor antagonist,” Funder said. – by Regina Schaffer
Disclosure: Funder reports financial or business/organizational interests with the Department of Veterans Affairs, Garnett Passe and the Rodney Williams Memorial Foundation and serving as a consultant for Pfizer/Japan. Please see the complete clinical practice guideline for the other authors’ relevant financial disclosures.
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