Is it time to screen all patients with hypertension for primary aldosteronism?

Yang, Jun; Fuller, Peter J.; Stowasser, Michael

doi:10.5694/mja17.00783

Cited by 22 publications

(29 citation statements)

References 29 publications

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“…Hypertension causes mechanical stress on the cardiovascular system, and this is exacerbated in PA due to the additional effects of excess aldosterone and MR activation which cause adverse tissue remodelling in the vasculature, heart and kidney 27 . PA is substantially under‐diagnosed in hypertensive patients 6,7 or diagnosed only after prolonged duration of hypertension 28 . Identifying unique clinical features of PA could facilitate its early diagnosis and treatment.…”

Section: Discussionmentioning

confidence: 99%

“…Targeted treatment is available for PA in the form of adrenalectomy for unilateral disease or mineralocorticoid receptor (MR) blockade for bilateral disease, both of which reduces the rate of cardiovascular complications 4,5 . There is now substantial evidence that PA is under‐diagnosed in many hypertensive patient populations 6‐8 . The traditional hallmarks of PA are hypertension and hypokalaemia.…”

Section: Introductionmentioning

confidence: 99%

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Comparison of ambulatory blood pressure between patients with primary aldosteronism and other forms of hypertension

Libianto

Menezes

Kaur

et al. 2020

Clinical Endocrinology

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Objective Primary aldosteronism (PA) is a potentially curable cause of hypertension associated with worse cardiovascular prognosis than blood pressure‐matched essential hypertension (EH). Effective targeted treatment for PA is available with the greatest benefit seen if treatment is started early, prior to the development of end‐organ damage. However, PA is currently substantially under‐diagnosed. The standard screening test for PA, the aldosterone‐to‐renin ratio (ARR), is performed infrequently in both primary and tertiary care. In contrast, ambulatory blood pressure monitoring (ABPM) is frequently utilized in the assessment of hypertension. The aim of this study was to compare ABPM parameters in hypertensive patients with and without PA, in order to identify features of ABPM associated with PA that can prompt screening. Study design Patients with PA (n = 55) were identified from a tertiary clinic specializing in the management of endocrine causes of hypertension whilst the controls (n = 389) were consecutive patients with hypertension but without a known diagnosis of PA who were referred for ABPM. Results In this study, PA patients were younger and had higher 24‐h, day, and night‐time blood pressure compared with controls despite similar number of antihypertensive medications. However, there was no significant difference in nocturnal dipping or day‐night blood pressure variability between the two groups. Conclusions An elevated ambulatory blood pressure in patients on multiple antihypertensives could suggest underlying PA but in the absence of other distinguishing features, ABPM could not reliably differentiate PA from other forms of hypertension. Routine biochemical screening for PA remained the most reliable way of detecting this treatable secondary cause of hypertension.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Comparison of ambulatory blood pressure between patients with primary aldosteronism and other forms of hypertension

Libianto

Menezes

Kaur

et al. 2020

Clinical Endocrinology

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“…Primary aldosteronism (PA), also known as Conn syndrome, is a secondary cause of hypertension characterised by the excessive secretion of aldosterone, autonomous of its principal regulator, angiotensin II 1 . An inappropriate excess of aldosterone increases cardiovascular, renal and metabolic morbidity and mortality 2,3 . PA has been demonstrated to account for 3–13% of hypertension in primary care, and up to 30% in referral centres 4 in a range of international studies.…”

Section: Introductionmentioning

confidence: 99%

“…1 An inappropriate excess of aldosterone increases cardiovascular, renal and metabolic morbidity and mortality. 2,3 PA has been demonstrated to account for 3-13% of hypertension in primary care, and up to 30% in referral centres 4 in a range of international studies. Despite its reported high prevalence in the hypertensive population, knowledge and active application of international guidelines 2 for screening for PA is low.…”

Section: Introductionmentioning

confidence: 99%

Impact of Victoria's first dedicated endocrine hypertension service on the pattern of primary aldosteronism diagnoses

Lim

Libianto

Shen

et al. 2021

Internal Medicine Journal

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Background Primary aldosteronism (PA) accounts for 3.2–12.7% of hypertension in primary care but is often diagnosed late, if at all. A delayed or missed diagnosis leads to poor blood pressure control and greater cardiovascular risk. Aims To analyse the impact of Victoria's first dedicated endocrine hypertension service (EHS) on the pattern of PA diagnosis. Methods Socio‐demographic and clinical data from all patients who attended the EHS since July 2016 (n = 267) was collected prospectively. Patients were divided into Year 1 (Y1), Year 2 (Y2) and Year 3 (Y3), based on their first visit. Results The proportion of primary care referrals increased (20% in Y1, 47% in Y2, 52% in Y3) with more referrals being made for treatment‐naive hypertension (3% in Y1, 14% in Y2, 19% in Y3). Among PA patients, the median duration of hypertension prior to their first visit decreased (11 years in Y1, 10 years in Y2, 7 years in Y3), and the prevalence of end‐organ damage decreased (44% in Y1, 42% in Y2, 33% in Y3). Targeted management of PA improved clinical and biochemical outcomes. The average blood pressure reduction following targeted management increased from 16/12 mmHg in Y1 to 23/12 mmHg in Y3. Conclusion The EHS, with its strong component of general practitioner engagement, led to increased primary care referrals and PA detection earlier in the course of hypertension. Referred patients were on fewer antihypertensives and had less end‐organ damage which simplified the diagnostic process, allowing targeted treatment to be commenced earlier and patient outcomes optimised.

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“…2,3 As PHA is treatable, it is important to identify patients with this condition in order to reduce morbidity and mortality. 4 Current diagnostic pathways usually incorporate a screening test, followed by confirmatory testing such as saline suppression or fludrocortisone suppression testing. 5…”

Section: Introductionmentioning

confidence: 99%

An LC-MS/MS assay for analysis of equilibrium angiotensin II in human serum

2021

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Background The current first-line screening test for primary hyperaldosteronism is the plasma aldosterone:renin ratio, however renin assays have several disadvantages and the ARR is affected by medications and physiological factors. Angiotensin II is a key biologically active hormone in the renin-angiotensin-aldosterone system. It has been suggested that measurement of equilibrium levels of this peptide, involving an in vitro incubation of serum prior to analysis, may provide a better marker of renin-angiotensin-aldosterone system activity than renin. Methods An eqAng II LC-MS/MS assay was developed, optimised and validated. Serum samples were incubated at 37 Â°C for 45 minutes prior to stabilisation with cold EDTA solution, solid phase extraction and LC-MS/MS analysis. Stability in whole blood and the effect of cryoactivation were assessed. For comparison to the current screening test, 150 anonymised patient samples were analysed for eqAng II, renin activity and aldosterone (all by LC-MS/MS). Results The assay had good precision, minimal bias and acceptable recovery. EqAng II did not change significantly when whole blood samples were stored for up to 72 h, and cryoactivation was only observed for pregnant patients. EqAng II was significantly correlated with renin, and the aldosterone:eqAng II ratio had a strong positive correlation with the aldosterone:renin ratio. Conclusions An LC-MS/MS assay for eqAng II has been developed which shows promise as an alternative screening test for primary hyperaldosteronism. Compared to renin assays it is quicker, simpler and less likely to be affected by anti-hypertensive medications. Further clinical validation in hypertensive patients would be required prior to implementation.

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Is it time to screen all patients with hypertension for primary aldosteronism?

Cited by 22 publications

References 29 publications

Comparison of ambulatory blood pressure between patients with primary aldosteronism and other forms of hypertension

Comparison of ambulatory blood pressure between patients with primary aldosteronism and other forms of hypertension

Impact of Victoria's first dedicated endocrine hypertension service on the pattern of primary aldosteronism diagnoses

An LC-MS/MS assay for analysis of equilibrium angiotensin II in human serum

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