Identifying Primary Aldosteronism in Primary Care

Practical Guide Explores Clinical Indicators for Identifying Primary Aldosteronism.

January 2024
Source:  Screening for primary aldosteronism in primary care
  1. Primary aldosteronism (PA) is common among patients with hypokalemia and hypertension. 

    Although most patients with PA are normokalemic , hypokalemia (either spontaneous or diuretic-induced) in a patient with hypertension should prompt testing for primary aldosteronism (PA). About 30% of patients with hypokalemia and hypertension seen in primary care have AP, but less than 5% of patients with recurrent hypertension and hypokalemia were examined in a Canadian setting.
     
  2. Patients with primary aldosteronism (PA) are at increased risk of chronic disease if undiagnosed or untreated. 

    The prevalence of primary aldosteronism (PA) in hypertensive patients in primary care is at least 4-6% and potentially higher depending on the screening thresholds used. If undiagnosed and untreated with targeted medical treatment or surgery, patients with AP have a disproportionately higher risk of cardiometabolic disease than matched controls with essential hypertension. Early diagnosis and targeted treatment are necessary to prevent the harmful effects of hyperaldosteronism.
     
  3. Expert consensus recommends screening for primary aldosteronism (PA) in high-risk populations. 

    Patients with severe or refractory hypertension, or patients with hypertension combined with other specific factors (hypokalemia, adrenal nodule, or family history of AP), should be evaluated for AP with the aldosterone-renin ratio.
     
  4. Most antihypertensive medications can be continued during the study for primary aldosteronism (PA). 

    It may not be feasible to stop antihypertensive medications during screening for primary aldosteronism (PA). In addition to mineralocorticoid receptor antagonists (spironolactone, eplerenone, and amiloride), most other antihypertensive medications can usually be continued. A suppressed renin in the setting of an angiotensin-converting enzyme inhibitor or angiotensin II receptor blockers is highly suspicious for AP.
     
  5. A high aldosterone to renin ratio suggests primary aldosteronism (PA). 

    In suspected cases of PA, referral to a hypertension or endocrine specialist is warranted for further investigations, including workup for unilateral disease that can be cured with surgery. Otherwise, empirical treatment with a mineralocorticoid receptor antagonist is recommended.
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