Subscribe to RSS
DOI: 10.1055/a-2048-6213
Improving Detection Rates for Primary Aldosteronism
![](https://www.thieme-connect.de/media/eced/20230708/lookinside/thumbnails/12-2022-0363-endo_10-1055-a-2048-6213-1.jpg)
Abstract
Primary aldosteronism (PA), once considered a rare disease, is being increasingly recognized as an important cause of hypertension. It is associated with higher rates of cardiovascular complications compared to blood pressure-matched essential hypertension. Targeted treatments are available which can mitigate the excess cardiovascular risks and, in some cases, cure hypertension. Making a timely diagnosis of PA is, therefore, highly beneficial for patients. Furthermore, numerous studies from different parts of the world have found PA to be a relatively common disease that can affect patients in any stage of hypertension, regardless of their age or potassium levels. Despite this well-established data, the current rate of PA detection is appallingly low, much below its actual prevalence. This review explores the challenges that clinicians often face in diagnosing PA and offers strategies that may improve the detection of this potentially curable form of hypertension.
Key words
Hypertension - Cardiovascular incidences - Cardiovascular risk management - Cardiovascular incidences - HormonesPublication History
Received: 30 December 2022
Received: 13 February 2023
Accepted: 26 February 2023
Article published online:
09 May 2023
© 2023. Thieme. All rights reserved.
Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany
-
References
- 1 Funder JW, Carey RM, Mantero F. et al. The management of primary aldosteronism: Case detection, diagnosis, and treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol 2016; 101: 1889-1916
- 2 Milliez P, Girerd X, Plouin PF. et al. Evidence for an increased rate of cardiovascular events in patients with primary aldosteronism. JACC 2005; 45: 1243-1248
- 3 Mulatero P, Monticone S, Bertello C. et al. Long-term cardio- and cerebrovascular events in patients with primary aldosteronism. J Clin Endocrinol 2013; 98: 4826-4833
- 4 Monticone S, D'Ascenzo F, Moretti C. et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: A systematic review and meta-analysis. Lancet Diabetes Endocrinol 2018; 6: 41-50
- 5 Catena C, Colussi G, Lapenna R. et al. Long-term cardiac effects of adrenalectomy or mineralocorticoid antagonists in patients with primary aldosteronism. Hypertension 2007; 50: 911-918
- 6 Catena C, Colussi G, Nadalini E. et al. Cardiovascular outcomes in patients with primary aldosteronism after treatment. Arch Intern Med 2008; 168: 80-85
- 7 Hundemer GL, Curhan GC, Yozamp N. et al. Cardiometabolic outcomes and mortality in medically treated primary aldosteronism: A retrospective cohort study. Lancet Diabetes Endocrinol 2018; 6: 51-59
- 8 Hundemer GL, Imsirovic H, Vaidya A. et al. Screening rates for primary aldosteronism among individuals with hypertension plus hypokalemia: A population-based retrospective cohort study. Hypertension 2022; 79: 178-186
- 9 Cohen JB, Cohen DL, Herman DS. et al. Testing for primary aldosteronism and mineralocorticoid receptor antagonist use among U.S. veterans: A retrospective cohort study. Ann Intern Med 2020; 174: 289-297
- 10 Libianto R, Fuller PJ, Young MJ. et al. Primary aldosteronism is a public health issue: challenges and opportunities. J Hum Hypertens 2020; 34: 478-586
- 11 Conn JW.. Primary aldosteronism, a new clinical syndrome. J Lab Clin Med 1955; 45: 3-17
- 12 Monticone S, Burrello J, Tizzani D. et al. Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice. JACC 2017; 69: 1811-1820
- 13 Xu Z, Yang J, Hu J. et al. Primary aldosteronism in patients in China with recently detected hypertension. JACC 2020; 75: 1913-1922
- 14 Libianto R, Russell GM, Stowasser M. et al. Detecting primary aldosteronism in Australian primary care: A prospective study. Med J Aust 2022; 216: 408-412
- 15 Fogari R, Preti P, Zoppi A. et al. Prevalence of primary aldosteronism among unselected hypertensive patients: A prospective study based on the use of an aldosterone/renin ratio above 25 as a screening test. Hypertens Res 2007; 30: 111-117
- 16 Kayser SC, Deinum J, de Grauw WJ. et al. Prevalence of primary aldosteronism in primary care: A cross-sectional study. Br J Gen Pract 2018; 68: e114-e122
- 17 Galati SJ, Cheesman KC, Springer-Miller R. et al. Prevalence of primary aldosteronism in an urban hypertensive population. Endocr Pract 2016; 22: 1296-1302
- 18 Volpe C, Wahrenberg H, Hamberger B. et al. Screening for primary aldosteronism in a primary care unit. JRAAS 2013; 14: 212-219
- 19 Ito Y, Takeda R, Karashima S. et al. Prevalence of primary aldosteronism among prehypertensive and stage 1 hypertensive subjects. Hypertens Res 2011; 34: 98-102
- 20 Westerdahl C, Bergenfelz A, Isaksson A. et al. Primary aldosteronism among newly diagnosed and untreated hypertensive patients in a Swedish primary care area. Scan J Prim Health Care 2011; 29: 57-62
- 21 Williams JS, Williams GH, Raji A. et al. Prevalence of primary hyperaldosteronism in mild to moderate hypertension without hypokalaemia. J Hum Hypertens 2006; 20: 129-136
- 22 Westerdahl C, Bergenfelz A, Isaksson A. et al. High frequency of primary hyperaldosteronism among hypertensive patients from a primary care area in Sweden. Scan J Prim Health Care 2006; 24: 154-159
- 23 Schwartz GL, Turner ST.. Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity. Clin Chem 2005; 51: 386-394
- 24 Loh KC, Koay ES, Khaw MC. et al. Prevalence of primary aldosteronism among Asian hypertensive patients in Singapore. J Clin Endocrinol 2000; 85: 2854-2859
- 25 Mosso L, Carvajal C, Gonzalez A. et al. Primary aldosteronism and hypertensive disease. Hypertension 2003; 42: 161-165
- 26 Gordon RD, Ziesak MD, Tunny TJ. et al. Evidence that primary aldosteronism may not be uncommon: 12% incidence among antihypertensive drug trial volunteers. Clin Exp Pharmacol Physiol 1993; 20: 296-298
- 27 Ma L, Song Y, Mei M. et al. Age-related cutoffs of plasma aldosterone/renin concentration for primary aldosteronism screening. Int J Endocrinol 2018; 2018: 8647026
- 28 Vaidya A, Mulatero P, Baudrand R. et al. The expanding spectrum of primary aldosteronism: Implications for diagnosis, pathogenesis, and treatment. Endocr Rev 2018; 39: 1057-1088
- 29 Funder JW. Primary aldosteronism: Where are we now? Where to from here?. Horm Metab Res 2020; 52: 459-466
- 30 Brown JM, Siddiqui M, Calhoun DA. et al. The unrecognized prevalence of primary aldosteronism. Ann Intern Med. 2020
- 31 Kayser SC, Dekkers T, Groenewoud HJ. et al. Study heterogeneity and estimation of prevalence of primary aldosteronism: A systematic review and meta-regression Analysis. J Clin Endocrinol 2016; 101: 2826-2835
- 32 Parasiliti-Caprino M, Lopez C, Prencipe N. et al. Prevalence of primary aldosteronism and association with cardiovascular complications in patients with resistant and refractory hypertension. J Hypertens 2020; 38: 1841-1848
- 33 Williams B, MacDonald TM, Morant S. et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): A randomised, double-blind, crossover trial. Lancet 2015; 386: 2059-2068
- 34 Williams B, MacDonald TM, Morant SV. et al. Endocrine and haemodynamic changes in resistant hypertension, and blood pressure responses to spironolactone or amiloride: The PATHWAY-2 mechanisms substudies. Lancet Diab Endocrinol 2018; 6: 464-475
- 35 Hu Y, Zhang J, Liu W. et al. Determining the prevalence of primary aldosteronism in patients with new-onset type 2 diabetes and hypertension. J Clin Endocrinol 2020; 105
- 36 Seccia TM, Letizia C, Muiesan ML. et al. Atrial fibrillation as presenting sign of primary aldosteronism: Results of the Prospective Appraisal on the Prevalence of Primary Aldosteronism in Hypertensive (PAPPHY) Study. J Hypertens 2020; 38: 332-339
- 37 Mulatero P, Monticone S, Burrello J. et al. Guidelines for primary aldosteronism: Uptake by primary care physicians in Europe. J Hypertens 2016; 34: 2253-2257
- 38 Rossi E, Perazzoli F, Negro A. et al. Diagnostic rate of primary aldosteronism in Emilia-Romagna, Northern Italy, during 16 years (2000-2015). J Hypertens 2017; 35 1691-1697
- 39 Yang J, Fuller PJ, Stowasser M.. Is it time to screen all patients with hypertension for primary aldosteronism?. Med J Aust 2018; 209: 57-59
- 40 Liu YY, King J, Kline GA. et al. Outcomes of a specialized clinic on rates of investigation and treatment of primary aldosteronism. JAMA Surg. 2021
- 41 Tan SJ, Libianto R, Yang J. et al. Screening for primary aldosteronism in the diabetic population: A cohort study. Intern Med J. 2022
- 42 Chauhan K, Schachna E, Libianto R. et al. Screening for primary aldosteronism is underutilised in patients with chronic kidney disease. J Nephrol. 2022
- 43 Lim YY, Shen J, Fuller PJ. et al. Current pattern of primary aldosteronism diagnosis: Delayed and complicated. Aust J Gen Pract 2018; 47: 712-718
- 44 Jaffe G, Gray Z, Krishnan G. et al. Screening rates for primary aldosteronism in resistant hypertension: A cohort study. Hypertension 2020; 75: 650-659
- 45 Burrello J, Monticone S, Losano I. et al. Prevalence of hypokalemia and primary aldosteronism in 5100 patients referred to a tertiary hypertension unit. Hypertension 2020; 75: 1025-1033
- 46 Stowasser M, Ahmed AH, Pimenta E. et al. Factors affecting the aldosterone/renin ratio. Horm Metab Res 2012; 44: 170-176
- 47 Suntornlohanakul O, Sakarin S, Kietsiriroje N. et al. Geographical inequality in service utilization for primary aldosteronism screening: Spatial epidemiological study in Southern Thailand. BMC Health Serv Res 2022; 22: 458
- 48 Cooke G, Valenti L, Glasziou P. et al. Common general practice presentations and publication frequency. Aust Fam Phys 2013; 42: 65-68
- 49 Nainani AK, Yang J, Peters S. et al. 'I can't understand why others don't screen more': A qualitative study exploring why Australian general practitioners screen for primary aldosteronism. BMJ Open 2022; 12: e061671
- 50 Schmiemann G, Gebhardt K, Hummers-Pradier E. et al. Prevalence of hyperaldosteronism in primary care patients with resistant hypertension. J Am Board Fam Med 2012; 25: 98-103
- 51 Wu J, Tian W, Zhang L. et al. Assessing the quality of guidelines for primary aldosteronism: Which guidelines are worth applying in diverse settings?. J Hypertens 2019; 37: 1500-1512
- 52 Funder JW, Carey RM, Fardella C. et al. Case detection, diagnosis, and treatment of patients with primary aldosteronism: An endocrine society clinical practice guideline. J Clin Endocrinol 2008; 93: 3266-3281
- 53 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. JACC 2018; 71: e127-e248
- 54 Williams B, Mancia G, Spiering W. et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension: The Task Force for the management of arterial hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36: 1953-2041
- 55 Li N, Huang J, Zheng B. et al. Cost-effectiveness analysis of screening for primary aldosteronism in China. Clin Endocrinol 2021; 95: 414-422
- 56 Lim YY, Libianto R, Shen J. et al. Impact of Victoria's first dedicated endocrine hypertension service on the pattern of primary aldosteronism diagnoses. Int Med J 2021; 51: 1255-1261
- 57 Funder JW, Carey RM.. Primary aldosteronism: Where are we now? Where to from here?. Hypertension 2022; 79: 726-735
- 58 Unger T, Borghi C, Charchar F. et al. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75: 1334-1357
- 59 Choy KW, Fuller PJ, Russell G. et al. Primary aldosteronism. Br Med J 2022; 377: e065250
- 60 GBD 2016 Causes of Death Collaborators. Global, regional, and national age-sex specific mortality for 264 causes of death, 1980-2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet 2017; 390: 1151-1210
- 61 Lim SS, Vos T, Flaxman AD. et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2224-2260