Reversing the established order: Should adrenal venous sampling precede cross‐sectional imaging in the evaluation of primary aldosteronism?

Asmar, M.; Wachtel, Heather; Yan, Yan; Fraker, Douglas L.; Cohen, Debbie L.; Trerotola, Scott O.

doi:10.1002/jso.23963

Cited by 10 publications

(4 citation statements)

References 31 publications

(39 reference statements)

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“…As previously published, AVS was performed using a modified Mayo protocol . Selectivity index (SI) was calculated as adrenal/caval cortisol; AVS was considered technically successful with SI of ≥3.…”

Section: Methodsmentioning

confidence: 99%

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

Gershuni

Ermer

Kelz

et al. 2019

Journal of Surgical Oncology

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Background: Primary aldosteronism (PA) is the most common cause of secondary hypertension; early diagnosis and intervention correlate with outcomes. We hypothesized that race may influence clinical presentation and outcomes.Methods: We conducted a retrospective analysis of patients with PA (1997PA ( -2017 who underwent adrenal vein sampling (AVS). Patients were classified by self-reported race as black or non-black. Improvement was defined as postoperative decrease in mean arterial pressure (MAP), antihypertensive medications (AHM), or both.Results: Among patients undergoing AVS (n = 443), 287 underwent adrenalectomy. Black patients (28.2%) had higher body mass index (33.9 vs 31.8 kg/m 2 ; P = .01), longer median duration of hypertension (12 vs 10 years; P = .003), higher modified Elixhauser comorbidity index (2 vs 1; P = .004), and lower median income ($47 134 vs $78 280; P < .001). Black patients had similar aldosterone:renin ratios (150 vs 135.6 [ng/dL]/[ng·mL· −1 hr −1 ]; P = .23) compared to non-blacks. At long-term follow-up, black patients had a similar requirement for AHM (1 vs 0; P = .13) but higher MAP (100.6 vs 95.3 mm Hg; P = .004).Conclusion: Black patients present with longer duration of hypertension and more comorbidities. They are equally likely to lateralize on AVS, suggesting similar disease phenotype. However, black patients demonstrate less improvement with adrenalectomy; this may reflect a delay in diagnosis or concomitant essential hypertension.adrenal, aldosteronoma, disparities, hypertension, primary aldosteronism, race 1 | INTRODUCTION Primary aldosteronism (PA) is the most common etiology of secondary hypertension, affecting 3% to 20% of hypertensive patients 1-4 and 14%to 21% of patients with resistant hypertension. 5 Hyperaldosteronism is associated with end organ dysfunction and cardiovascular morbidity and mortality, independent of level of hypertension. 6-8 As compared to those with essential hypertension, patients with PA have increased risk of myocardial infarction, atrial fibrillation, and stroke, in excess of the projected risk related to degree of hypertension alone. 9 Effective control of blood pressure (BP) and aldosterone level lead to improved cardiovascular outcomes. 10 Therefore, early diagnosis and appropriate treatment of PA is essential to improve cardiovascular outcomes and minimize end organ dysfunction. Subtype differentiation of PA is an essential component of early diagnosis and treatment. Unilateral causes of PA include aldosteroneproducing adenoma and unilateral hyperplasia, which are potentially The authors have no disclosures.surgically curable, while bilateral adrenal hyperplasia (BAH) is managed medically with mineralocorticoid antagonists. 11 Shorter duration of disease has been associated with improved operative outcomes in multiple studies of subjects with unilateral PA. 12,13 An extensive literature exists on race and hypertension, particularly as it pertains to black patients. 14,15 Racial disparities in diagnosis, prevalence, treatment, and outcomes, a...

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Section: Methodsmentioning

confidence: 99%

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

Gershuni

Ermer

Kelz

et al. 2019

Journal of Surgical Oncology

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“…Several studies demonstrated that MRI has poorer resolution and slower acquisition than CT, with a risk of respiratory artefacts and that MRI is inferior to adrenal CT in PA subtype evaluation. [17][18][19][20] Contrast materials can improve the visibility of adrenal structures imaged by CT and MRI scans and might have a positive effect on diagnosis accuracy. 21 Thus, imaging methods and contrast materials were thought to be confounders for subgroup analyses.…”

Section: Discussionmentioning

confidence: 99%

Diagnostic accuracy of adrenal imaging for subtype diagnosis in primary aldosteronism: systematic review and meta-analysis

et al. 2020

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ObjectivesAccurate subtype classification in primary aldosteronism (PA) is critical in assessing the optimal treatment options. This study aimed to evaluate the diagnostic accuracy of adrenal imaging for unilateral PA classification.MethodsSystematic searches of PubMed, EMBASE and the Cochrane databases were performed from 1 January 2000 to 1 February 2020, for all studies that used CT or MRI in determining unilateral PA and validated the results against invasive adrenal vein sampling (AVS). Summary diagnostic accuracies were assessed using a bivariate random-effects model. Subgroup analyses, meta-regression and sensitivity analysis were performed to explore the possible sources of heterogeneity.ResultA total of 25 studies, involving a total of 4669 subjects, were identified. The overall analysis revealed a pooled sensitivity of 68% (95% CI: 61% to 74%) and specificity of 57% (95% CI 50% to 65%) for CT/MRI in identifying unilateral PA. Sensitivity was higher in the contrast-enhanced (CT) group versus the traditional CT group (77% (95% CI 66% to 85%) vs 58% (95% CI 50% to 66%). Subgroup analysis stratified by screening test for PA showed that the sensitivity of the aldosterone-to-renin ratio (ARR) group was higher than that of the non-ARR group (78% (95% CI 69% to 84%) vs 66% (95% CI 58% to 72%)). The diagnostic accuracy of PA patients aged ≤40 years was reported in four studies, and the overall sensitivity was 71%, with 79% specificity. Meta-regression revealed a significant impact of sample size on sensitivity and of age and study quality on specificity.ConclusionCT/MRI is not a reliable alternative to invasive AVS without excellent sensitivity or specificity for correctly identifying unilateral PA. Even in young patients (≤40 years), 21% of patients would have undergone unnecessary adrenalectomy based on imaging results alone.

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“…Its specificity is excellent, so much so that current guidelines recommend the use of cross-sectional imaging in conjunction with AVS [22]. However, to our knowledge the sensitivity of AVS has not been assessed as a function of left and right side cases, despite anatomical differences.…”

Section: Introductionmentioning

confidence: 99%

“…In a previous publication, we reported on our experience in AVS and we insisted on those [6]. Preoperative AVS is mandatory for surgical decision making in the case of primary aldosteronism (PA) without any radiological target on abdominal CT scan, as it gives a definitive evaluation for the lateralization of PA [6, 22].…”

Section: Introductionmentioning

confidence: 99%

Anatomical Variations of the Venous Drainage from the Left Adrenal Gland: An Anatomical Study

et al. 2016

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No connections have been found between left adrenal vein and the RLAT, and frequency of the IPV is discordant with the literature. However, our findings concerning the capsular vessels' anastomosis with the azygos system, inferior diaphragmatic flow and double adrenal vein could have two clinical applications: Firstly, the ligation of the adrenal vein solely is not enough to entirely interrupt the adrenal vein drainage, and secondly, sampling of hormones in the LAV could be underestimated because of the risk of dilution.

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Reversing the established order: Should adrenal venous sampling precede cross‐sectional imaging in the evaluation of primary aldosteronism?

Abstract: An AVS-first, imaging-second approach could have avoided CT/MRI in 43% of patients. At a high volume, experienced center, performing AVS first on patients with PA may reduce unnecessary cross-sectional imaging studies.

Cited by 10 publications

References 31 publications

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

Clinical presentation and surgical outcomes in primary aldosteronism differ by race

Diagnostic accuracy of adrenal imaging for subtype diagnosis in primary aldosteronism: systematic review and meta-analysis

Anatomical Variations of the Venous Drainage from the Left Adrenal Gland: An Anatomical Study

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