Corticotropin Stimulation in Adrenal Venous Sampling for Patients With Primary Aldosteronism

Abstract

ImportanceAdrenal venous sampling (AVS) is usually recommended to distinguish between unilateral and bilateral primary aldosteronism (PA) before definitive surgical or medical treatment is offered. Whether a treatment decision based on AVS with or without corticotropin (ACTH) stimulation leads to different biochemical and clinical remission rates in patients with PA remains unclear.ObjectiveTo evaluate whether treatment decisions based on AVS with or without ACTH stimulation lead to different biochemical and clinical remission rates in patients with PA.Design, Setting, and ParticipantsThis randomized clinical trial (RCT) was conducted at a tertiary hospital in China from July 8, 2020, to February 20, 2023, among patients with PA aged 18 to 70 years. Patients were followed up for 12 months after the initiation of treatment. An intention-to-diagnose analysis was conducted.InterventionsPatients were randomly assigned to undergo either ACTH-stimulated or non–ACTH-stimulated AVS.Main Outcomes and MeasuresThe primary end point was the proportion of patients with complete biochemical remission after 12 months of follow-up. Secondary outcomes included the proportion of patients who achieved complete clinical remission after 12 months of follow-up, dosages of antihypertensive agents, rate of successful bilateral AVS, and adverse events.ResultsOf 228 patients with PA, 115 were randomized to the non–ACTH-stimulated group (median age, 50.0 years [IQR, 41.0-57.0 years]; 70 males [60.9%]) and 113 to the ACTH-stimulated group (median age, 50.0 years [IQR, 43.5-56.5 years]; 63 males [55.8%]). A total of 68 patients (59.1%) underwent adrenalectomy in the non-ACTH group and 65 (57.5%) in the ACTH group. There was no significant difference in the proportion of patients with complete biochemical remission who were managed on the basis of AVS with vs without ACTH stimulation (with: 56 of 113 [49.6%]; without: 59 of 115 [51.3%]; P = .79). There also was no significant difference in the proportion of patients who achieved complete clinical remission between the non-ACTH and ACTH groups (26 of 115 [22.6%] and 31 of 113 [27.4%], respectively; P = .40). The intensity of therapy with antihypertensives, successful catheterization of bilateral adrenal veins, and incidence of adverse events did not significantly differ between the non-ACTH and ACTH groups.Conclusions and RelevanceIn this RCT, treatment of PA on the basis of non–ACTH-stimulated or ACTH-stimulated AVS did not lead to significant differences in clinical outcomes for the patients. These results suggest that ACTH stimulation during AVS may not have clinical benefit, at least in the Chinese population.Trial RegistrationClinicalTrials.gov Identifier: NCT04461535

Effect of adrenocorticotropic hormone stimulation during adrenal vein sampling for the subtyping of primary aldosteronism: a prospective study

“…Consistent with our study, most of the studies concluded that in patients who already lateralized with unstimulated sampling, the response to ACTH did not have any impact on surgical outcomes [16,19,26,27,35]. Yang et al [36] designed a randomized controlled trial in which patients were randomly assigned to either the ACTH stimulated or non-ACTH stimulated group when sequential AVS. They found the treatment of primary aldosteronism on the basis of ACTH stimulation did not result in significant differences in biochemical and clinical outcomes.…”