‘Widespread missed opportunities’ for primary aldosteronism testing among veterans
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Testing for primary aldosteronism was rare among a cohort of U.S. veterans with treatment-resistant hypertension, yet was associated with higher rates of evidence-based treatment and better longitudinal blood pressure control, data show.
“Although guidelines recommend testing for primary aldosteronism in all patients with treatment-resistant hypertension, we found very low rates of screening for primary aldosteronism — on average 2% across centers — and only 13% of patients were started on mineralocorticoid receptor antagonists when most of them should have been,” Jordana B. Cohen, MD, MSCE, assistant professor of medicine and epidemiology in the Renal-Electrolyte and Hypertension Division at the Perelman School of Medicine at the University of Pennsylvania, told Healio. “Testing for primary aldosteronism was associated with a fourfold greater likelihood of starting a mineralocorticoid receptor antagonist therapy and with much better blood pressure control over time, regardless of the results of the screening.”
As Healio previously reported, primary aldosteronism, an adrenal disorder and a secondary cause of hypertension, has historically been considered a rare condition. However, in a cross-sectional study of more than 1,000 adults published in May in Annals of Internal Medicine, researchers measured the degree of renin-independent aldosterone production in every BP category — including normal levels — and estimated the prevalence of biochemically overt primary aldosteronism at 11.3% among normotensive adults and higher at 22% among those with resistant hypertension.
In a retrospective study, Cohen and colleagues analyzed data from 269,010 veterans with apparent treatment-resistant hypertension from 2000 to 2017, defined as two measurements of at least 140 mm Hg systolic or 90 mm Hg diastolic at least 1 month apart during use of three or more antihypertensive agents (including a diuretic) or hypertension requiring four or more antihypertensive classes (median age, 65 years; 4% women; 19% Black).
Researchers assessed rates of primary aldosteronism testing via measurement of plasma aldosteronerenin level and the association of testing with evidence-based treatment using MRA therapy and with longitudinal systolic BP.
Within the cohort, 4,277 patients, or 1.6%, were tested for primary aldosteronism after a median of 3.3 years.
Researchers found that an index visit with a nephrologist (HR = 2.05; 95% CI, 1.66-2.52) or an endocrinologist (HR = 2.48; 95% CI, 1.69-3.63), but not a cardiologist, was associated with a higher likelihood for testing compared with primary care. Testing was associated with a fold higher likelihood of initiating MRA therapy (HR = 4.1; 95% CI, 3.68-4.55) with results persisting after adjustment for patient-, provider- and center-level factors.
Veterans who underwent testing had higher baseline systolic BP compared with those who did not undergo testing; however, testing was associated with an average 1.32 mm Hg lower systolic BP over time in unadjusted analyses. In adjusted analyses, testing for primary aldosteronism was associated with an average 1.47 mm Hg lower systolic BP over time compared with no testing, with results persisting after adjustment for MRA use.
“The findings suggest that there are widespread and concerning missed opportunities for primary aldosteronism screening and for appropriate treatment of patients with treatment-resistant hypertension,” Cohen said. “The observation that screening practices are strongly associated with evidence-based treatment of treatmentresistant hypertension and blood pressure control over time suggests that good provider behaviors beget other good behaviors, that there are major gaps in provider knowledge of the importance of screening these patients, and that there are likely barriers to implementing appropriate management for these patients.”
The researchers noted that, given the unique infrastructure of the , there is an opportunity to introduce innovative practices to meaningfully improve education of providers and increase testing to enhance management in this high-risk patient population.
“Future studies should evaluate implementation of tools to identify patients via the electronic health record and alert providers to their appropriateness for testing,” the researchers wrote.
Perspective
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James W. Findling, MD
This is an interesting study with results that are not unexpected — fewer than 2% of patients with resistant hypertension are screened for primary aldosteronism. This finding is consistent with studies from other health care systems. Even among patients with hypokalemia, only 5% were screened. Also unsurprising is that referral to an endocrinologist or nephrologist increased the likelihood for screening and that cardiologists were no help. Cardiologists need to get on board with this.
My cynical side says that I am a bit surprised that screening was even this good. For crying out loud, Dr. Conn described this disorder in the 1950s and predicted it would be a common cause of hypertension. Many thought he was crazy. Turns out he was a prophet.
What can be done to improve this? I like the authors’ conclusions stating that they see this as an opportunity for increasing awareness of this problem and the need to improve education of providers regarding primary aldosteronism. For several years, I have suggested that CMS and all the many health care bureaucracies that litigate “quality” should use screening for primary aldosteronism in hypertensive patients as an index of quality. If they did that, screening would increase immediately. Since that will not happen, endocrinologists should be leaders in this effort — leaders by example. We should be screening all our patients with suboptimal blood pressure control for primary aldosteronism. That kind of effort will trickle down to primary care — this may take years — and then they will start screening more often.
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