Primary aldosteronism: Are we diagnosing and operating on too few patients?

Gordon, Richard D.; Stowasser, Michael; Rutherford, John C.

doi:10.1007/s00268-001-0033-4

Cited by 88 publications

(43 citation statements)

References 46 publications

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“…Adenomas/hyperplasias o1 cm could be possibly missed on CT scan and therefore, if suppression tests confirm the diagnosis of PH, adrenal venous sampling (AVS) is indicated. 8 Furthermore, the use of ARR as the screening test has important clinical implicationsF more patients would be diagnosed and possibly cured when surgically treated. However, the indications for the use of the ARR in all hypertensive patients still remain controversialFsome authors dispute the validity of such an application.…”

Section: Introductionmentioning

confidence: 99%

Prevalence of primary hyperaldosteronism in moderate to severe hypertension in the Central Europe region

et al. 2003

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Recently published studies from different parts of the world report significantly higher prevalence of primary hyperaldosteronism (PH) in hypertensives (ranging from 5 to 25%) than the previously accepted figures. There have been no data so far about the prevalence of PH in Central Europe. Therefore, we have undertaken this study to evaluate the prevalence of PH in patients with moderate to severe hypertension referred to a hypertension unit in the Czech Republic, together with the determination of the percentage of different subtypes of PH including familial forms. In addition to that, we have evaluated the prevalence of other types of secondary forms of hypertension.A total of 402 consecutive patients (230 females and 172 males) with hypertension, referred to our hypertension unit, were studied. Positive aldosterone/renin ratio (ARR, (ng/100 ml)/(ng/ml/h)) X50 as a more strict marker of PH was found in 87 patients (21.6%), 30% of them were normokalaemic. The diagnosis of PH was later confirmed in 77 cases (89%); the total prevalence of PH was thus 19%. PH consisted of the following forms: idiopathic hyperaldosteronism 42%, unilateral aldosterone-producing adenoma 36%, unilateral hyperplasia 7%, nonclassifiable PH (refused operation/adrenal venous sampling) 13%, familial hyperaldosteronism type 1.2%. The prevalence of other types of secondary hypertension was as follows: pheochromocytoma 5%, renovascular 4.5%, hypercortisolism 2%, renal 0.75%.In conclusion, we have noted that PH in the Central Europe region (Czech Republic) is the most frequent form of endocrine hypertension with a considerably high prevalence in moderate to severe hypertension. Application of more strict criteria raises the probability of correct diagnosis of PH including the early normokalaemic stages of PH.

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Section: Introductionmentioning

confidence: 99%

Prevalence of primary hyperaldosteronism in moderate to severe hypertension in the Central Europe region

et al. 2003

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“…1,5 However, multiple studies have shown that the accuracy of adrenal CT in localizing the source of aldosterone excess is poor (approximately 50%) and that in patients with primary aldosteronism who wish to pursue the surgical option for hypertension management, AVS is a key step in distinguishing between unilateral and bilateral adrenal disease. 1,[5][6][7][8][9][10][11][12][13] Some centres and a recent clinical practice guideline recommend that AVS be performed in all patients who have the diagnosis of primary aldosteronism and who want to pursue surgical management. 1,13 A more practical approach is the selective use of AVS who want to pursue the surgical option in the management of their hypertension.…”

mentioning

confidence: 99%

“…1,[5][6][7][8][9][10][11][12][13] Some centres and a recent clinical practice guideline recommend that AVS be performed in all patients who have the diagnosis of primary aldosteronism and who want to pursue surgical management. 1,13 A more practical approach is the selective use of AVS who want to pursue the surgical option in the management of their hypertension. doxazosin, terazosin and prazosin).…”

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confidence: 99%

What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism?

Young

Stanson

2008

Clinical Endocrinology

191

156

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SummaryAdrenal venous sampling (AVS) is the criterion standard to distinguish between unilateral and bilateral adrenal disease in patients with primary aldosteronism. The keys to successful AVS include appropriate patient selection, careful patient preparation, focused technical expertise, defined protocol, and accurate data interpretation. The use of AVS should be based on patient preferences, patient age, clinical comorbidities, and the clinical probability of finding an aldosterone-producing adenoma. AVS is optimally performed in the fasting state in the morning. AVS is an intricate procedure because the right adrenal vein is small and may be difficult to locate -the success rate depends on the proficiency of the angiographer. The key factors that determine the successful catheterization of both adrenal veins are experience, dedication and repetition. With experience, and focusing the expertise to 1 or 2 radiologists at a referral centre, the AVS success rate can be as high as 96%. A centre-specific, written protocol is mandatory. The protocol should be developed by an interested group of endocrinologists, radiologists and laboratory personnel. Safeguards should be in place to prevent mislabelling of the blood tubes in the radiology suite and to prevent sample mix-up in the laboratory.

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“…45 Instead, a detailed time-consuming evaluation is necessary, especially in all hypertensive patients, to rule out primary aldosteronism which may be the cause of hypertension in up to 15% of these patients. 43,44 In a normotensive patient with a serum potassium level greater than 3.9 nmol/L, no further hormonal evaluation is necessary. The screening for subclinical primary aldosteronism should include, in addition to serum potassium, the upright aldosterone level to plasma renin activity (PRA) ratio, since a single value of aldosterone may be normal.…”

Section: Screening or Subclinical Primary Aldosteronismmentioning

confidence: 99%

Adrenal Incidentaloma (Adrenaloma)

Linos

2003

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The management of adrenalomas should include the following: 1. A detailed history and physical examination to detect subtle evidence of hormonal hypersecretion or the possibility of metastatic carcinoma. Hormonal studies:Short dexamethasone suppression test (2 mg of dexamethasone) followed by a high-dose dexamethasone suppression test (8 mg), CRH assay and analysis of the diurnal cortisol rhythm if serum cortisol value post dexamethasone is greater than 3ìg/dL 24-hour (or spot) urinary catecholamine metabolites (metanephrine and normetanephrine) In the hypertensive or normotensive patient with serum potassium less than 3.9 nmol/L, the upright aldosterone level to plasma renin activity (PRA) ratio. 3. Additional studies, such as Glucose tolerance test Bone mineral density evaluation Body composition and fat distribution by DEXA (Dual energy X-Ray absorptiometry). The role of .NA is limited. It may be helpful only in the patient with coexistent extradrenal carcinoma to confirm adrenal metastasis. Although genetic and molecular biology studies do not have wide clinical application, they should be encouraged and supported. Once all of these data are collected, the recommendations are: 1. All clearly nonfunctioning adrenalomas that are not suspicious for malignancy in asymptomatic patients should be observed for several years, mainly with hormonal studies, until their secretory and benign nature is confirmed. 2. All patients with adrenalomas and evidence of subclinical function, suspicion for malignancy (using size, imaging, .NA and molecular biology criteria) and symptoms, such as hypertension, obesity, impaired glucose tolerance, central fat deposition and reduced bone mineral density, should undergo laparoscopic adrenalectomy. The age, the overall medical condition and the anxiety of the patient should also be considered in the decision to operate on a patient with an adrenaloma.

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Primary aldosteronism: Are we diagnosing and operating on too few patients?

Cited by 88 publications

References 46 publications

Prevalence of primary hyperaldosteronism in moderate to severe hypertension in the Central Europe region

Prevalence of primary hyperaldosteronism in moderate to severe hypertension in the Central Europe region

What are the keys to successful adrenal venous sampling (AVS) in patients with primary aldosteronism?

Adrenal Incidentaloma (Adrenaloma)

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