Summary A study of more than 200,000 adults with hypertension and 1 risk factor for primary aldosteronism finds that <4% are generally screened, often after cardiovascular and renal complications have already occurred. |
Primary aldosteronism ( PA) is the main cause of endocrine hypertension, with an estimated prevalence of at least 10% among patients with hypertension, and more than 20% of cases of resistant hypertension. Primary aldosteronism (PA) increases the risk of renal and cardiovascular morbidity and mortality through direct insults to target organs, independent of hypertension.
Inappropriate activation of mineralocorticoid receptors leads to myocardial fibrosis, endothelial dysfunction, and microalbuminuria. Prompt diagnosis of AP and targeted therapy with unilateral adrenalectomy or mineralocorticoid receptor antagonists can mitigate excessive cardiovascular and renal risk.
Expert guidelines recommend PA screening in patients with resistant hypertension, hypertension, and hypokalemia, and in those with early-onset hypertension. Additionally, Endocrine Society guidelines recommend PA screening in patients with hypertension and obstructive sleep apnea (OSA) or an adrenal mass.
However, the AP remains largely underrecognized. Across the United States Veterans Health Administration and at select academic institutions, AP screening was reported in only ~3% of patients with resistant hypertension. Underestimation of the prevalence of PA, complex testing logistics, and lack of familiarity with interpretation of results have been attributed to underdiagnosis of PA.
Data comparing PA screening among at-risk populations are minimal. Several indications for AP screening, including resistant hypertension, OSA, and adrenal masses, are common among the age group most affected by AP. However, it is unknown whether PA detection occurs more frequently in patients with multiple risk factors.
To better understand the gaps in PA recognition, we aimed to compare detection patterns across all major indications, alone and in combination, at a large tertiary referral center with nationally recognized adrenal expertise.
Background
Primary aldosteronism (FA) is a common but underrecognized cause of secondary hypertension. Data directly comparing screening rates between single and overlapping indications are lacking.
Methods and results
We conducted a retrospective review of adults with hypertension seen in outpatient clinics at an academic tertiary referral center between January 1, 2017 and June 30, 2020.
Patients with hypertension plus at least one of the following were included: resistant hypertension; age<35 years; obstructive sleep apnea; hypokalemia; or an adrenal mass. Patients with adrenal insufficiency, severe renal disease or heart failure, and renovascular hypertension were excluded. Of 203,535 patients with hypertension, 86,044 (42.3%) met at least 1 FA screening criterion, and of these, 2898 (3.4%) were screened for FA.
Screening occurred in 2.7% of patients with resistant hypertension; 4.2% of people with obstructive sleep apnea; 5.1% of those <35 years old; 10.0% of people with hypokalemia; and 47.3% of patients with adrenal mass.
Screening rates were higher in patients with multiple risk factors : 16.8% for ≥3, 5.7% for 2, and 2.5% for 1 criterion.
Multiple logistic regression showed that the odds of FA screening were higher in patients with hypokalemia : odds ratio (95% CI): 3.0 (2.7–3.3); women: 1.3 (1.2–1.4); Black versus white: 1.5 (1.4–1.7); those with obstructive sleep apnea, chronic kidney disease, stroke and dyslipidemia.
Conclusions
Consideration of primary aldosteronism occurs in a small subset of at-risk patients, and typically after comorbidities have developed.
Clinical perspective What’s new? Primary aldosteronism (PA) screening rates and patterns were compared in at-risk populations in a large outpatient academic setting. We found that while patients with resistant hypertension and those with hypertension and obstructive sleep apnea constitute the largest risk groups, they have the lowest PA detection rates. PA screening is performed more frequently in women, black patients, those with hypertension and hypokalemia or adrenal nodules, and those with multiple risk factors for PA. What are the clinical implications? Of patients with hypertension and at least one risk factor for PA, only 3.4% are evaluated for PA. Detection of AP is triggered more frequently in patients with multiple risk factors and after cardiovascular and renal complications have occurred. Efforts to encourage AP detection by clinicians at the forefront of hypertension management are critical to preventive medicine. |
In summary , in this study of more than 200,000 patients with hypertension, we compared PA screening rates across various indications supported by international expert guidelines. We found that patients with resistant hypertension and those with hypertension and OSAS represent the largest risk groups , yet they are rarely screened for AP. In contrast, patients with adrenal nodules and those with 3 or more risk factors for FA are offered screening more frequently.
Our data suggest that PA screening is triggered more frequently in patients with multiple risk factors and after cardiovascular and renal complications have occurred. To prevent such complications, efforts to encourage AP screening among internists and primary care physicians, who are at the forefront of hypertension treatment, are critical.
