Genetics, prevalence, screening and confirmation of primary aldosteronism: a position statement and consensus of the Working Group on Endocrine Hypertension of The European Society of Hypertension

Clinical value of CXCR4-targeted PET-CT in primary aldosteronism: a systematic review and meta-analysis

PURPOSE

Primary aldosteronism (PA), a common cause of secondary hypertension, requires precise localization and subtype differentiation for appropriate management. C-X-C chemokine receptor 4 (CXCR4) targeted PET-CT emerges as a promising non-invasive modality for evaluating PA. This study aims to assess its performance in three key areas: lateralizing aldosterone secretion, differentiating PA subtypes, and predicting surgical outcomes.

METHODS

A systematic review and meta-analysis were performed, including studies that evaluated CXCR4-targeted PET-CT for PA diagnosis. Relevant literature was retrieved from PubMed, Embase, Scopus, Web of Science, WanFang, and CNKI (through January 10, 2025). Studies were included if they provided data on lateralization, subtype differentiation, or postoperative outcomes. Risk of bias was assessed using the QUADAS-2 tool. Pooled diagnostic metrics were calculated using random-effects models, with summary receiver operating characteristic curves analysis.

RESULTS

Fourteen studies involving 1043 patients were included. CXCR4-targeted PET-CT demonstrated a pooled sensitivity of 74%[95%CI: 69-79%] and specificity of 85%[95%CI: 64-95%] for lateralizing aldosterone secretion. For subtype differentiation, sensitivity was 91%[95%CI: 82-96%] and specificity 92%[95%CI: 85-96%] in distinguishing aldosterone-producing adenoma from non- aldosterone-producing adenoma. In predicting postoperative outcomes, the sensitivity was 91%[95%CI: 84-95%], with accuracy of 77%[95%CI: 64-90%].

CONCLUSION

CXCR4-targeted PET-CT demonstrated clinical applications in: (1) accurately determining PA lateralization with high specificity; (2) reliably distinguishing PA subtypes; and (3) effectively predicting postoperative benefit. These findings support its potential use as an adjunctive tool in the clinical management of PA.

SYSTEMATIC REVIEW REGISTRATION NO

CRD42025636887 (PROSPERO).

Genetic Testing for Primary Aldosteronism in SPAIN: Results From the SPAIN-ALDO Registry and Review of the Literature

CONTEXT

It is estimated that about 5% of the primary aldosteronism (PA) cases are of hereditary origin (familial hyperaldosteronism, FH). To date, 4 forms of FH have been reported. However, in general little is known about the genetic causes that lead to the development of PA.

OBJECTIVE

This work aimed to determine the rate of genetic testing for FH in the SPAIN-ALDO Registry and to describe the clinical characteristics of patients with FH. In addition, a literature review of reports of FH cases was performed.

METHODS

A retrospective multicenter study of PA in patients followed in 35 Spanish tertiary hospitals (SPAIN-ALDO Registry).

RESULTS

Twenty-five of the 855 patients (3%) with PA included in the registry underwent genetic testing for FH, with complete results available for only 24 patients. However, we found that there were 57 patients who met the criteria for performing a genetic study of PA. Only 8 out of these 57 patients were genetically tested (14.0%), while the reasons to perform a genetic study in the remaining 17 genetically studied cases were quite heterogeneous. A positive result for FH was found in only one case for FH type III (KCNJ5 pathogenic variant). A systematic review of the literature was performed and identified a total of 25 articles reporting 246 patients with FH type I, 12 articles reporting 72 patients with FH type II, 14 articles reporting 29 cases of FH type III, and 3 articles reporting 12 patients with FH type IV.

CONCLUSION

The genetic study of FH is often scarce in real-world clinical practice, as 86% of patients with criteria to undergo genetic study were not evaluated in our cohort. Nevertheless, FH is an uncommon cause of PA, representing only 0.2% of cases in the SPAIN-ALDO Registry, although its prevalence may be as high as 4% among suspected cases.

Impact of primary aldosteronism on calcium phosphate homeostasis. Results from the SPAIN-ALDO

PURPOSE

To determine the prevalence of hyperparathyroidism (HPT), including primary, secondary and normocalcemic in a cohort of patients with PA of the SPAIN-ALDO registry.

METHODS

A retrospective multicenter study of primary aldosteronism (PA) patients followed in 37 Spanish tertiary hospitals and with available information on serum calcium, phosphorus, iPTH, and vitamin D at the time of PA diagnosis. The diagnosis of normocalcemic HPT (n-HPT) associated with PA was based on a iPTH > 65pg/mL with normal corrected serum calcium after excluding the most common causes of secondary HPT, and HPT was classified as secondary (S-HPT) in the presence of chronic kidney disease or vitamin D deficiency, and as primary (PHPT) when iPTH levels >65 pg/mL were associated with high serum calcium levels.

RESULTS

A total of 246 patients with PA were included, of whom 56% (n = 139) had PTH > 65 pg/mL. In the group of participants with HPT (n = 139) the proportion of PHPT was 7.2%, of n-HPT 11.5% and of S-HPT 81.3%. Patients with n-HPT had a higher prevalence of atrial fibrillation (7.9% vs. 1.9%, P = 0.04) and hypokalemia (71.6% vs. 46.2%, P < 0.001) and greater aldosterone (33.2 vs. 26.8 ng/dL, p = 0.003) and 24 h urinary calcium excretion ( 243.5 vs. 160.5 mg/24 h, p = 0.01) than patients without hyperparathyroidism. No differences in surgical outcomes (biochemical and clinical response) were detected between patients with and without hyperparathyroidism.

CONCLUSIONS

HPT is a frequent condition in patients with PA and S-HPT is the most common etiology. Patients with HPT have a higher prevalence of atrial fibrillation and hypokalemia and a more severe PA than those without HPT. However, no differences in surgical outcomes were reported between patients with and without HPT.

Advances in the biochemical diagnostics of primary aldosteronism: from immunoassays to steroidomics and proteomics

Primary aldosteronism is the most common cause of secondary hypertension, yet most cases remain unrecognized and left without optimal treatment. The diagnostic inertia may be attributed to the lack of specific symptoms, insufficient awareness among physicians, still conflicting indications for screening for primary aldosteronism and first and foremost challenging diagnostics. This review describes the current challenges of biochemical diagnostics of primary aldosteronism, including screening, case confirmation and subtyping. It also discusses immunoassays widely used in assessment of suspected autonomous aldosterone secretion - recent advances in the field and limitations of the method in comparison to the gold standard - liquid chromatography -tandem mass spectrometry. The review focuses on the application of novel "omics" strategies in the diagnostics of primary aldosteronism. Steroidomics and proteomics offer a possibility to simultaneously assess steroids and protein/peptides on a large scale. This multianalyte approach in comparison to the selective quantification of a chosen compound has been proved useful in the diagnostics of primary aldosteronism. It also offers a unique insight into the individual characteristics, underlying mechanisms and even reflects the genetic alterations of primary aldosteronism cases. The "omics" techniques are associated with large amounts of generated data, the interpretation of which may be troublesome and often necessitates the use of artificial intelligence. The novel advances in the biochemical diagnostics of primary aldosteronism, including "omics" techniques, presented in this review may help to address the most emerging problems, increase the number of diagnosed patients and facilitate the choice of an optimal treatment.

Unmasking primary aldosteronism: Transforming disease management with advanced steroid profiling

Primary aldosteronism (PA) is traditionally thought to result from the overproduction of aldosterone which is unregulated by the renin-angiotensin system. It leads to a significantly increased risk of cardiovascular and metabolic complications as compared to primary hypertension. However, approximately one-third of patients diagnosed with PA according to the traditional guidelines have been found to exhibit low aldosterone levels and other steroid hormones may also play a potentially critical role in PA development. Early diagnosis of PA remains challenging due to low screening rates and the complex diagnostic procedures. The need for invasive adrenal vein sampling for PA subtyping also leads to a dilemma in therapeutic strategy selection. With advances in techniques, an increasing number of steroid hormones have been discovered to be associated with PA, potentially optimizing the PA diagnostic procedures. Herein, we review the cutting-edge advances in steroid hormones, including aberrant hormone synthesis and metabolism related to the pathophysiological development of PA, quantitative assays, and potential clinical value. Mass spectrometry provides a robust technical foundation for the simultaneous profiling of a panel of steroid hormones. Steroid hormone profiling combined with machine learning algorithms holds great research promise for facilitating early diagnosis and minimally invasive subtyping of PA. Thus, current progress and future expectations in combining steroid hormones with advanced technologies for early disease diagnosis and management are also reviewed. Research Agenda. 1) Identify changes in steroid hormones and the underlying biochemical mechanisms associated with PA. 2) Investigate the role of advanced mass spectrometry techniques in steroid hormone profiling. 3) Discuss current advances and future expectations in combining machine learning algorithms with MS-based steroid hormone profiling for PA's systematic and practical management.

Clinical significance of parathyroid hormone in mineral and glucose metabolism disorders among patients with primary aldosteronism

Objective

To investigate the differences in mineral and glucose metabolic disorders among patients with primary aldosteronism, nonfunctional adrenal tumors, and controls.

Methods

A retrospective analysis was conducted on clinical data from 578 patients, including those with primary aldosteronism, nonfunctional adrenal tumors, and control subjects, at our hospital between January 2013 and December 2023. Biochemical indices including parathyroid hormone, serum potassium, serum calcium, urine potassium, urine calcium, plasma renin, plasma aldosterone, glycosylated hemoglobin, insulin resistance index, and pancreatic beta cell function index were compared among the three groups.

Results

Compared with the nonfunctional adrenal tumors and control groups, primary aldosteronism patients exhibited significantly higher levels of parathyroid hormone, urinary potassium, and aldosterone (p < 0.05), while their serum potassium and serum calcium levels were significantly lower (p < 0.05). Additionally, primary aldosteronism patients had higher glycosylated hemoglobin levels, lower HOMA-IR, and lower HOMA-β levels (p < 0.05). Pearson's correlation analysis revealed that serum parathyroid hormone levels were negatively correlated with serum potassium, serum calcium, serum renin activity, and HOMA-β levels, while positively correlated with urinary potassium, urine calcium, blood carbon dioxide combining power, urine pH, serum aldosterone, and HOMA-IR levels. Stepwise regression analysis indicated that HOMA-IR and aldosterone were the main factors influencing parathyroid hormone levels. Based on receiver operating characteristic curve analysis, the optimal cut-off value for parathyroid hormone in diagnosing primary aldosteronism was 62.1 pg/ml, with a sensitivity of 94.4% and specificity of 81.0%.

Conclusion

Primary aldosteronism is often characterized by elevated parathyroid hormone levels, which can exert direct adverse effects on mineral and glucose metabolism. Elevated parathyroid hormone levels serve as a valuable indicator in the screening of primary aldosteronism.

A Phase I/IIa Clinical Trial to Evaluate Safety and Adrenal Uptake of Para-Chloro-2-[18F]Fluoroethyletomidate in Healthy Volunteers and Patients with Primary Aldosteronism

Primary aldosteronism (PA) is a common, potentially reversible, cause of hypertension. Distinguishing unilateral from bilateral PA is critical when deciding who should be offered surgery (unilateral adrenalectomy). Recent studies have shown that PET/CT with [11C]metomidate can accurately identify unilateral PA, with localization of the causative aldosterone-producing adenoma (APA). However, the availability of [11C]metomidate is limited to centers with an on-site cyclotron. Here, we report an early-phase human study with the 18F-labeled analog, para-chloro-2-[18F]fluoroethyletomidate ([18F]CETO). Methods: We conducted a phase I/IIa, single-center, open-label, microdosing study. The primary objective was to evaluate the safety of up to 2 administrations of [18F]CETO in 6 patients with PA (3 unilateral disease, 3 bilateral disease) and 5 healthy volunteers. Safety evaluation included assessment of adrenal function after the first [18F]CETO administration. The biodistribution of [18F]CETO was assessed in a 90-min dynamic PET acquisition. In patients with PA, the effect of pretreatment with oral dexamethasone on [18F]CETO uptake by normal adrenal tissue and APAs was also assessed. Results: Eleven participants were recruited to the trial, including 6 patients and 5 healthy volunteers. No subjects experienced serious adverse events or reactions, and all participants had normal adrenal function after [18F]CETO administration. [18F]CETO demonstrated high selectivity for the adrenal glands with low uptake in other tissues. Visualization of APAs was enhanced after dexamethasone pretreatment, which suppressed [18F]CETO uptake by normal adrenal tissue. Conclusion: [18F]CETO is a safe radiopharmaceutical for PET imaging of the adrenal glands, with no observed adverse reactions or impairment of adrenal function in this study. [18F]CETO demonstrates selective high affinity for adrenal tissue, particularly APAs. Distinction between APAs and normal adrenal tissue is enhanced by dexamethasone pretreatment to suppress [18F]CETO uptake by normal glands. This positions [18F]CETO as a promising imaging tool for evaluation in the context of PA.

Prevalence and main characteristics of primary aldosteronism in bilateral macronodular adrenal disease: a systematic review of the literature

CONTEXT

Bilateral macronodular adrenal disease (BMAD) typically presents with bilateral benign adrenocortical macronodules and variable cortisol excess. Anecdotal evidence suggests oversecretion of other adrenal steroids, including mineralocorticoids.

HYPOTHESIS

We hypothesized that primary aldosteronism (PA) can occur in BMAD, resulting in a distinct, more severe phenotype compared to BMAD with isolated cortisol hypersecretion or unilateral PA (uPA).

OBJECTIVE

To assess the prevalence and characteristics of PA in BMAD.

METHODS

We systematically reviewed case reports and series of BMAD patients with PA, following PRISMA guidelines. BMAD was defined by bilateral adrenal nodules ≥10 mm. PA diagnosis followed US or Japanese Endocrine Society guidelines. We compared these findings with 2 cohorts from LMU Hospital Munich: BMAD with isolated cortisol hypersecretion and uPA.

RESULTS

From 1018 articles, 18 representing 68 cases were included. Of these, 66 had BMAD with PA and 2 had BMAD with aldosterone precursor excess. The PA proportion in published BMAD series ranged from 2% to 43%. BMAD patients with PA were predominantly male (75%) and younger (median 51.5 years) than those with isolated cortisol hypersecretion (median 60.5 years, P < .01). Their median blood pressure was higher (170/100 mm Hg) compared to those with isolated cortisol hypersecretion (138/80 mm Hg) or uPA (153/94 mm Hg, P < .01). Treatment was only described in 28 cases, with 93% undergoing adrenalectomy. Clinical outcome was similar across groups post-treatment.

CONCLUSION

This review highlights the need for increased screening for PA in younger, hypertensive BMAD patients. Larger multicenter studies are needed to determine the association between these conditions, cardiovascular risk, and optimal treatment.

Nationwide, Pragmatic, Direct-to-Patient Primary Aldosteronism Testing Program

BACKGROUND

Primary aldosteronism, an endocrinopathy present in ≥10% to 25% of patients with hypertension, confers excess cardiovascular risk that can be mitigated with aldosterone-directed therapy. However, only 2% of eligible patients undergo guideline-recommended screening. This study aimed to bypass clinical inertia and identify people with primary aldosteronism using pragmatic, direct-to-patient testing.

METHODS

Hypertensive adults were recruited via online platforms and underwent virtual consent and local phlebotomy. Using a standardized diagnostic algorithm, laboratory results with interpretations were communicated to patients and primary care providers. Follow-up was ascertained at 6 to 12 months. The primary outcome was the frequency of a positive test for primary aldosteronism. Secondary outcomes included follow-up primary aldosteronism testing and implementation of aldosterone-targeted therapies.

RESULTS

The study population (N=694) had a mean age of 63.3±11.3 years, was 52.2% female, and hailed from 41 US states. Overall, 25.4% had a positive test for primary aldosteronism. Sleep apnea, resistant hypertension, and hypokalemia were the most common testing indications, with 55.2% of participants having ≥2 indications. Over half of participants (57%) were already under endocrinology, cardiology, or nephrology care, yet had not been tested. In longitudinal follow-up of participants with a positive result, 25.5% had additional testing and 13.7% were started on aldosterone-targeted therapy (mineralocorticoid receptor antagonist or adrenalectomy).

CONCLUSIONS

Pragmatic, direct-to-patient testing, and simplified results interpretation is a feasible, scalable method to increase primary aldosteronism diagnoses and implementation of aldosterone-targeted therapies. Given that new hypertension guidelines recommend primary aldosteronism screening in all hypertensive people, practical approaches to test, interpret, and implement results will be essential.

Cross-sectional association between plasma aldosterone concentration and cognitive performance by mini-mental state examination in community dwellers

Background

Aldosterone is the effector hormone in the renin angiotensin aldosterone system and existing data suggest aldosterone affect cognitive function. However, the relationship between plasma aldosterone concentration (PAC) and cognitive performance remains unexplored in community dwellers. Therefore, we aimed to explore whether PAC is associated with cognitive performance in this population.

Methods

We cross-sectionally enrolled adults using multistage random sampling from Emin, China in 2019. Participants underwent questionnaires and data collection. Cognitive status was assessed using mini-mental state examination (MMSE) questionnaire. Multi-variable linear and logistic regression were used to explore the association between log PAC and log MMSE score, and between tertiled PAC (the higher PAC as the exposure) and low cognitive performance, respectively, in total, apparently healthy and diseased participants. Subgroup analyses also were performed by age, gender, BMI, living region, ethnicity and education attainment status.

Results

27,707 subjects were included, of whom, 12,862 were apparently healthy and 14,845 had disease. Log-PAC was positively associated with log-MMSE score in the multivariable linear regression in the total (B = 0.01, 95%CI: 0-0.01, p < 0.001), apparently healthy (B = 0.01, 95%CI: 0-0.01, p = 0.007) participants, and the diseased without taking medicine (B = 0.01, 95%CI: 0.01-0.02, p = 0.004) participants. In logistic regression, the highest third tertile of PAC group showed significantly lower odds for the presence of low cognitive performance in total (OR = 0.83, 95%CI: 0.73-0.93, p = 0.002) and diseased without taking medicine participants (OR = 0.70, 95%CI: 0.57-0.86, p < 0.001). Various sub-group analysis showed largely consistent results with the main analysis.

Conclusion

There was a positive correlation between plasma aldosterone and cognitive functions in community dwellers, whereas further studies are need when considering the cross-sectional nature of the current study.

The relationship between tissue inhibitor of metalloproteinases-1 and KCNJ5 mutation in aldosterone-producing adenoma patients

KCNJ5 somatic mutations in aldosterone-producing adenoma (APA) are linked to higher left ventricular mass index (LVMI) and worse diastolic function. We previously identified an association between plasma tissue inhibitor of metalloproteinases-1 (TIMP-1) and an aldosterone-induced increase in LVMI and diastolic dysfunction. This study aimed to investigate the association between the presence of KCNJ5 somatic mutation and plasma TIMP-1 in APA patients. We enrolled 60 APA patients undergoing adrenalectomy, including 30 with KCNJ5 mutations (KCNJ5(+)) and 30 without (KCNJ5(-)). Clinical characteristics, echocardiographic data (including LVMI, inappropriately excessive LVMI (ieLVMI), and diastolic function) and plasma TIMP-1 levels were measured before surgery and 1 year postoperatively. The results showed that the KCNJ5(+) group had higher plasma TIMP-1 levels (P = 0.004) compared to the KCNJ5(-) group. The correlation between the KCNJ5 mutations and TIMP-1 levels remained significant after multiple regression analysis. To detect KCNJ5 mutations, receiver operating characteristic curve analysis showed TIMP-1 had the best area under the curve (AUC) value among various clinical parameters (AUC = 0.682, 95% confidence interval = 0.549-0.796, P = 0.008). Post-adrenalectomy, only the KCNJ5(+) group showed significant decrease in LVMI (P = 0.001) and log-transformed TIMP-1 levels (P = 0.035). Changes in ieLVMI before and after surgery were consistently correlated with changes in TIMP-1 levels in multivariable regression analysis. In conclusion, KCNJ5 somatic mutations in APA are associated with higher plasma TIMP-1 levels. In addition, TIMP-1 is an effective biomarker for detecting the presence of KCNJ5 mutations in APA patients.

Screening of primary aldosteronism and pheochromocytoma among patients with hypertension: an Italian nationwide survey

PURPOSE

The delayed or missed diagnosis of secondary hypertension contributes to the poor blood pressure control worldwide. This study aimed to assess the diagnostic approach to primary aldosteronism (PA) and pheochromocytoma (PHEO) among Italian centers associated to European and Italian Societies of Hypertension.

METHODS

Between July and December 2023, a 10-items questionnaire was administered to experts from 82 centers of 14 Italian regions and to cardiologists from the ARCA (Associazioni Regionali Cardiologi Ambulatoriali) Piemonte. Results were stratified for geographical area, specialty, and center category (excellence vs. non-excellence centers).

RESULTS

Each center diagnosed an average of 2 cases of PA and 0.2 cases of PHEO annually, with higher figures in excellence centers. PA screening is performed mainly in patients with resistant hypertension (73.2%) or hypertension and spontaneous hypokalemia (84.1%), while only 17.1% and 35.4% of centers screen patients with grade 2-3 hypertension. Screening rate is lower for cardiologists compared to other specialists. The main barriers to wider testing were challenges in interpreting the aldosterone/renin ratio under interfering medications and switching to non-interfering drugs. Clinical scores to predict the likelihood of PA and the definition of Standard Operating Procedures were identified as potential tools to boost screening rates. Testing for PHEO was mostly conducted in patients with typical symptoms (75.6%) and/or hypertensive crisis (74.4%). Only 37.8% of centers screened all patients with adrenal incidentaloma.

CONCLUSION

This study highlights significant gaps in the screening and diagnosis of PA and PHEO across Italian centers and underscores the need for widespread and standardized diagnostic protocols.

Approach to Endocrine Hypertension: A Case-Based Discussion

PURPOSE OF REVIEW

Hypertension remains a major chronic disease morbidity across the world, even in the twenty-first century, affecting ≈40% of the global population, adversely impacting the healthcare budgets in managing the high incidence of cardiovascular disease (CVD) complications and mortality because of elevated blood pressure (BP). However, evaluation and management of endocrine hypertension are not optimal in clinical practice. With three unique clinical case scenarios, we update the evidence base for diagnostic evaluation and management of endocrine hypertension in this review to inform appropriate day-to-day clinical practice decisions.

RECENT FINDINGS

Although most individuals with high BP suffer from essential hypertension (≈85%), some patients may have a clear underlying etiology (termed secondary hypertension), and a significant proportion of these patients have endocrine hypertension (≈10%) consequent to hormone excess from dysfunction of one or more endocrine glands. Even if a relatively common disease in the general population, the correct diagnosis and appropriate treatment of endocrine hypertension is often delayed because of poor awareness among clinicians, including primary care providers and physicians in the secondary care settings. An accurate and timely diagnosis of endocrine hypertension is crucial to potentially cure or at least properly manage these patients because the consequences of delays in diagnosis can be catastrophic, with markedly higher end-organ complications such as CVD, chronic kidney disease, and even premature mortality among sufferers.

Advances in multimodal imaging for adrenal gland disorders: integrating CT, MRI, and nuclear medicine

Adrenal diseases pose significant diagnostic challenges due to the wide range of neoplastic and non-neoplastic pathologies. Radiologists have a crucial role in diagnosing and managing these conditions by, leveraging advanced imaging techniques. This review discusses the vital role of computed tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine in adrenal imaging, and focuses on morphological and functional evaluations. First, the anatomy and physiology of the adrenal glands are described, followed by a discussion on ectopic adrenocortical adenomas and how they develop. The concepts and imaging findings of congenital diseases, such as congenital adrenal hyperplasia (CAH), adrenal rest tumors, and adrenocortical nodular disease, considering recent updates to the WHO Classification of Tumours (5th ed.) terminology are highlighted. The diagnostic value of dynamic contrast-enhanced CT and chemical-shift MRI for identifying adrenocortical adenomas are emphasized, alongside the use of adrenocortical scintigraphy such as 131I-adosterol scintigraphy for diagnosing Cushing's disease, Cushing's syndrome (CS), subclinical CS, and ectopic adrenocorticotropic hormone-producing tumors. Systemic complications associated with CS, and the diagnosis and treatment of pheochromocytomas, paragangliomas (PPGLs), and neuroblastomas, will also be discussed focusing on 123I-metaiodobenzylguanidine (MIBG) imaging and 131I-MIBG therapy. Pitfalls in 123I-MIBG imaging and the increasing importance of diagnosing hereditary PPGLs due to increased genetic testing are also be discussed. Additionally, the broad differential diagnosis for adrenal masses-including malignancies like adrenal carcinoma, metastases, and malignant lymphoma, as well as benign conditions like myelolipoma and ganglioneuroma, and complications, such as adrenal hemorrhage, infarction, and infections-will be outlined. The goal of this review was to provide an overview of adrenal diseases that includes the most recent information for radiologists to stay updated on the latest imaging techniques and advancements that can ensure accurate diagnosis and effective management.

Adrenal Vein Sampling for Primary Aldosteronism: Recommendations From the Australian and New Zealand Working Group

Adrenal vein sampling (AVS) is the current recommended procedure for identifying unilateral subtypes of primary aldosteronism (PA), which are amenable to surgery with the potential for cure. AVS is a technically challenging procedure usually undertaken by interventional radiologists at tertiary centres. However, there are numerous variations in AVS protocols relating to patient preparation, sampling techniques and interpretation which may impact the success of AVS and patient care. To reduce practice variations, improve the success rates of AVS and optimise patient outcomes, we established an Australian and New Zealand AVS Working Group and developed evidence-based expert consensus recommendations for the preparation, performance and interpretation of AVS. These recommendations can be used by all healthcare professionals in a multidisciplinary team who look after the diagnosis and management of PA.

Visualization of Right Adrenal Vein in Non-Contrast-Enhanced MDCT and Its Guiding Role for Right Adrenal Venous Sampling

This study aimed to evaluate the visualization of right adrenal vein (RAV) in non-contrast-enhanced multi-detector computed tomography (MDCT) and its guiding role for right adrenal venous sampling (AVS) in patients with primary aldosteronism (PA). A total of 237 patients diagnosed with PA who underwent successful AVS procedures from January 2020 to March 2021 were retrospectively analyzed. The non-contrast-enhanced MDCT image features of RAV included the degree of visualization and the position of RAV orifice. Subsequently, the concordance degree between RAV in non-contrast-enhanced MDCT and AVS images was calculated to evaluate its guiding effect for right AVS. The visualization rate of RAV in non-contrast-enhanced MDCT was 81.9% (n = 194), with 73.7% (n = 143) clearly displayed and 26.3% (n = 51) generally displayed. In 6.2% (n = 12) of patients who can display RAV, RAV formed a common trunk with the accessory hepatic vein and then merged into the inferior vena cava. Non-contrast-enhanced MDCT revealed that RAV orifice was located between the 10th thoracic vertebra (T10) and the 1st lumbar vertebra (L1), with 85.1% (n = 165) located from the lower 1/3 of T11 to the lower 1/3 of T12. The concordance of imaging anatomy of RAV between non-contrast-enhanced MDCT and AVS image was found to be at a high rate of 94.3% (n = 183). Non-contrast-enhanced MDCT provides excellent visualization of RAV and clearly depicts its anatomical characteristics. Furthermore, RAV images obtained from non-contrast-enhanced MDCT are highly consistent with those from AVS, indicating that interpretation of non-contrast-enhanced MDCT before AVS can reduce the failure rate of RAV cannulation.

Comparison of a chemiluminescence immunoassay with LC-MS/MS in the determination of the plasma aldosterone concentration in patients with impaired renal function

PURPOSE

Compared with chemiluminescence immunoassay (CLIA), the quantification of the plasma aldosterone concentration (PAC) via liquid chromatography-tandem mass spectrometry (LC-MS/MS) yields lower values. The extent to which this difference is exacerbated by a reduced glomerular filtration rate (eGFR) is unclear. Therefore, this study aims to assess the impact of renal insufficiency on PAC as measured by CLIA using LC-MS/MS as the reference method.

METHODS

In subjects with a normal or reduced estimated eGFR, the PAC was measured using both LC-MS/MS and two different CLIA kits (Mindray and Liaison).

RESULTS

In total, 383 patients were included in our study. Among them, 71 subjects had eGFRs > 90 (Group one), 79 had eGFRs range from 60 to 89 (Group two), 108 had eGFR range from 30 to 59 (Group three), 51 had eGFRs range from 15 to 29 (Group four), and 74 had eGFRs < 15 (Group five) ml/min per 1.73 m2. In all the subjects, PAC as measured by CLIA [68.2 (37.1-122.1) pg/ml for Mindray, 109.0 (68.1-170.0) pg/ml for Liaison] were significantly higher than those measured by LC-MS/MS [47.2 (22.9-88.7) pg/ml]. PAC as measured by CLIA was positively correlated with PAC as measured by LC-MS/MS, but the correlation coefficient gradually decreased as eGFR decreased. Between the LC-MS/MS and Liaison CLIA kits, the difference in PAC values increased with reduced eGFR in groups one through five (76.8 %, 69.2 %, 113.2 %, 152.2 %, and 476.2 % for groups one through five, respectively). However, this difference increased only in Group five with the Mindray CLIA kit (46.4 %, 48.1 %, 45.7 %, 45.0 %, and 74.9 % for groups one through five, respectively).

CONCLUSION

CLIA progressively overestimated PAC as eGFR decreased, particularly with the Liaison method, indicating the need for caution when interpreting these measurements in patients with impaired renal function. In patients with impaired renal function, LC‒MS/MS measurements for PAC are preferable.

Optimizing the aldosterone-to-renin ratio cut-off for screening primary aldosteronism based on cardiovascular risk: a collaborative study

OBJECTIVES

Aldosterone-to-renin ratio (ARR) based screening is the first step in the diagnosis of primary aldosteronism (PA). However, the guideline-recommended ARR cutoff covers a wide range, from the equivalent of 1.3 to 4.9 ng·dl-1/mIU∙l-1. We aimed to optimize the ARR cutoff for PA screening based on the risk of cardiovascular diseases (CVD).

METHODS

Longitudinally, we included hypertensive participants from the Framingham Offspring Study (FOS) who attended the sixth examination cycle and followed up until 2014. At baseline (1995-1998), we used circulating concentrations of aldosterone and renin to calculate ARR (unit: ng·dl-1/mIU∙l-1) among 1,433 subjects who were free of CVD. We used spline regression to calculate the ARR threshold based on the incident CVD. We used cross-sectional data from the Chongqing Primary Aldosteronism Study (CONPASS) to explore whether the ARR cutoff selected from FOS is applicable to PA screening.

RESULTS

In FOS, CVD risk increased with an increasing ARR until a peak of ARR 1.0, followed by a plateau in CVD risk (hazard ratio 1.49, 95%CI 1.19-1.86). In CONPASS, when compared to essential hypertension with ARR < 1.0, PA with ARR ≥ 1.0 carried a higher CVD risk (odds ratio 2.24, 95%CI 1.41-3.55), while essential hypertension with ARR ≥ 1.0 had an unchanged CVD risk (1.02, 0.62-1.68). Setting ARR cutoff at 2.4 ~ 4.9, 10% ~30% of PA subjects would be unrecognized although they carried a 2.45 ~ 2.58-fold higher CVD risk than essential hypertension.

CONCLUSIONS

The CVD risk-based optimal ARR cutoff is 1.0 ng·dl-1/mIU∙l-1 for PA screening. The current guideline-recommended ARR cutoff may miss patients with PA and high CVD risk.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov (NCT03224312).

Clinical practice guideline for the management of hypertension in China

In China, hypertension is the most common chronic non-communicable disease and the most significant risk factor for cardiovascular mortality among urban and rural residents. To standardize the clinical diagnosis and treatment of hypertension and to improve the prevention and control level of hypertension in China, Chinese Society of Cardiology, Chinese Medical Association; Hypertension Committee of Cross-Straits Medicine Exchange Association; Cardiovascular Disease Prevention and Rehabilitation Committee, Chinese Association of Rehabilitation Medicine, jointly collaborated to formulate the Clinical Practice Guideline for Hypertension Management in China. The Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to rate the quality of evidence and strength of recommendations, and the reporting items for practice guidelines in healthcare (RIGHT) were followed to establish the guideline. Detailed evidence-based recommendations for the diagnosis, evaluation, and treatment of 44 clinical questions in the field of hypertension, including essential and secondary hypertension, have been provided to guide clinical practice.

REGISTRATION

International Practice Guidelines Registry Platform, http://www.guidelines-registry.cn/ , No. IPGRP-2021CN346.

Unravelling a mystery of hypokalemic hypertension- a rare case report of a reninoma

BACKGROUND

Reninoma is a rare cause of secondary hypertension, which can be cured with surgery if identified early before any target organ damage occurs. It leads to hypokalaemia and hypertension and typically responds well to treatment with renin-angiotensin-aldosterone system blockers. However, confirmation of the diagnosis and the localisation of this rare culprit lesion can be challenging.

CASE PRESENTATION

We describe a case of young-onset hypertension in a 19-year-old girl due to a reninoma. She had resistant hypertension with marked hypokalaemia, which required exceedingly high doses of potassium supplements. Biochemical Investigations revealed secondary hyperaldosteronism. Thus, she underwent a renal angiogram to exclude a renovascular cause for her hypertension. While the renal artery anatomy was normal, there was an exophytic renal lesion in the lower pole of the left kidney. Hence, the diagnosis of a reninoma was suspected. She underwent renal vein sampling to confirm the functionality of the detected tumour, but the results were inconclusive. After a multidisciplinary discussion, based on the clinical evidence, the renal lesion was thought to be a reninoma and a partial nephrectomy was done, removing the lesion. Immediately following resection, her blood pressure and potassium normalised without further drug treatment, and the resected lesion was later confirmed to be a reninoma by histopathological examination.

CONCLUSION

In young people with hypokalemic hypertension, reninoma should be considered when the more common causes are excluded since prompt treatment with excision of the culprit lesion can cure hypertension and prevent associated morbidity and mortality.

Diagnosis of Primary Aldosteronism without Discontinuation of Interfering Antihypertensive Medications

PURPOSE OF REVIEW

One of the challenges in the diagnosis and management of primary aldosteronism (PA), the most common type of secondary hypertension with curative potential, is the modification of antihypertensive medications. We seek to explore whether these medications can be continued during the diagnostic process of PA to minimize the duration and risks associated with medication adjustments.

RECENT FINDINGS

We searched PubMed for eligible original literature between 1990 and 2024 using the following keywords: (screening) AND (primary aldosteronism); (confirmatory) AND (primary aldosteronism); (adrenal vein sampling) AND primary aldosteronism). Some recent studies support the feasibility of PA-related tests and even adrenal vein sampling (AVS) without the need to discontinue antihypertensive medications in certain cases. In this review, we propose a management approach that considers the specific effects of antihypertensive medications on the RAAS axis and the patient's disease phenotype. Based on this, we suggest a strategy that enables the diagnosis of PA in certain patients without discontinuing their antihypertensive medications.

Diagnostic efficacy of aldosterone-to-renin ratio to screen primary aldosteronism in hypertension: a systemic review and meta-analysis

Background

The aldosterone-to-renin ratio (ARR) is commonly used for screening primary aldosteronism (PA) in patients with difficult-to-control hypertension. Various thresholds have been proposed for the confirmatory tests, leading to inconsistency in the results.

Objectives

This study aimed to elucidate the performance of ARR screening in hypertensive patients.

Design

Systemic review and meta-analysis.

Data sources and methods

PubMed, Embase, and the Cochrane Library were systematically searched from inception to January 2024. Studies that used the ARR to screen for PA and provided a comprehensive probability panel specifically focusing on hypertensive individuals were considered for enrollment. Pooled diagnostic efficacy was evaluated, and subgroup analyses and meta-regression were conducted based on different demographic and clinical parameters.

Results

Eighteen observational studies encompassing 7150 participants were included in the meta-analysis. The overall prevalence of PA in the hypertensive cohort was 15.2%, and pooled sensitivity and specificity were 81.6% and 93.3%, respectively, resulting in a diagnostic odds ratio of 62.0. Fagan's nomogram showed that a positive ARR increased the post-test probability to 80% from a pre-test probability of 25%. Summary receiver operating characteristic curve analysis revealed an area under the curve of 94.7%. Notably, analysis of variability demonstrated that the diagnostic performance was consistent across either ARR based on plasma renin activity or direct renin concentration, geographic region, sex, mean age, potassium level, and systolic blood pressure.

Conclusion

ARR was validated as a viable screening methodology for PA in hypertensive individuals. Moreover, its diagnostic efficacy remained unchanged across diverse clinical contexts. Future studies are warranted to refine ARR methodologies and enhance diagnostic accuracy.

Trial registration

PROSPERO ID number CRD42023493680.

Infographics

Performance of PA screening by ARR. ARR, aldosterone-to-renin ratio; BP, blood pressure; DRC, direct renin concentration; hsROC, hierarchical summary receiver operating characteristic; PA, primary aldosteronism; PRA, plasma renin activity.

Somatic GNAQ, CTNNB1, and CACNA1C Mutations in Cat Aldosterone-Secreting Tumors

BACKGROUND

Primary aldosteronism (PA) is a common cause of human hypertension. Somatic mutations in KCNJ5, CACNA1D, ATP1A1, and ATP2B3 are found in at least 80% of aldosterone-producing adenomas, which cause unilateral PA in humans. Somatic mutations have been identified infrequently in 7 other genes; few of these were known to play a role in aldosterone secretion before the discovery of their mutations. Interrogating somatic mutations in the domestic cat, in which spontaneous PA is also known to occur, might improve the understanding of normal adrenal gland physiology and the pathophysiology of PA.

METHODS

DNA and RNA extracted from tissue from 13 cats with unilateral aldosterone-secreting tumors, including 8 carcinomas and 5 adenomas, underwent whole genome sequencing, targeted Sanger sequencing, and RNA sequencing. Single-nucleotide substitution variants were filtered to select those with a predicted deleterious effect on protein function and a suspected role in aldosterone secretion.

RESULTS

Probable functional somatic single-nucleotide polymorphisms (n=8) were found in 3 adenomas and 2 carcinomas. Mutations with predicted significant effects were identified in 2 genes also mutated in human PA; GNAQ and CTNNB1, and in a residue of CACNA1C analogous to a common CACNA1D mutation. In contrast to humans, CACNA1C expression was much greater than CACNA1D in both feline tumor and nontumor adrenal tissue. No mutations were identified in KCNJ5, CACNA1D, ATP1A1, or ATP2B3.

CONCLUSIONS

Similar mutations were identified in cats to those found in humans. It is, therefore, likely that both species have shared underlying selection pressures for mutations that increase aldosterone secretion.

Performance of Aldosterone-to-renin Ratio Before Washout of Antihypertensive Drugs in Screening of Primary Aldosteronism

OBJECTIVE

The aim of this study is to evaluate performance of aldosterone-to-renin ratio (ARR) before washout of antihypertensive drugs as a screening test for primary aldosteronism (PA).

METHODS

This retrospective analysis included consecutive patients screening for secondary hypertension during a period from January 2017 to May 2022 at the authors' institute. For inclusion in the final analysis, ARR had to be available prior to as well as after discontinuation of antihypertensives. Patients with ARR ≥2.4(ng/dL)/(μIU/mL) after washout proceeded to confirmatory tests. Diagnosis of PA was established based on a positive result of the confirmatory test. The diagnostic accuracy of ARR prior to the washout in predicting PA is shown as sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

RESULTS

The analysis included a total of 1306 patients [median age of 50.2 (41.0-59.0) years, 64.0% male]. Confirmatory tests showed PA in 215(16.5%) patients and essential hypertension (EH) in the remaining 1091(83.5%) patients. In comparison to the second screening test, the first screening test (before washout of antihypertensives) yielded lower plasma aldosterone and higher renin and consequently lower ARR in both the PA and EH groups. At a cutoff of .7(ng/dL)/(μIU/mL), ARR before washout had 96.3% sensitivity, 61.2% specificity, .33 PPV, and .99 NPV. At a lower cutoff of .5(ng/dL)/(μIU/mL), the sensitivity, specificity, PPV, and NPV were 97.7%, 52.0%, .29, and .99, respectively.

CONCLUSION

ARR prior to washout of antihypertensives is a sensitive screening test for PA. Washout of antihypertensives could be omitted and further investigation for PA is not warranted if ARR is ≤ .7(ng/dL)/(μIU/mL) before washout.

Respiratory Displacement of the Right Adrenal Vein: Comparison of Inspiratory and Expiratory Computed Tomography With Catheter Venography

OBJECTIVE

The aim of the study is to reveal the respiratory displacement of the right adrenal vein (RAV) to predict the exact location of the RAV during adrenal venous sampling (AVS).

METHODS

Computed tomography (CT) scans obtained 45 seconds (breath-hold at inhalation) and 70 seconds (breath-hold at exhalation) after contrast material injection were compared to venograms of the RAV of patients with primary aldosteronism who underwent AVS between January 2016 and December 2020. The craniocaudal distance between the center of the Th11/12 disc and the RAV orifice was measured; the craniocaudal location of the RAV orifice was also specified relative to vertebral bodies and intervertebral discs on inspiratory phase CT (In-CT), expiratory phase CT (Ex-CT), and catheter venography. The transverse and vertical angles of the RAV and the position of the RAV orifice on the inferior vena cava (IVC) circumference were measured on In-CT and Ex-CT.

RESULTS

In total, 51 patients (30 males, 21 females; mean age, 54.9 ± 11.1 years) were included. Craniocaudal distances between the center of the Th11/12 disc and RAV orifice were significantly different among the following 3 acquisitions: catheter venography versus In-CT (15.2 ± 8.4 mm); venography versus Ex-CT (5.6 ± 4.1 mm); and In-CT versus Ex-CT (19.6 ± 8.0 mm) (all, P < 0.001). The craniocaudal location of the RAV orifice on venography was significantly closer to that on Ex-CT than on In-CT ( P < 0.001); measurements using venograms compared with In-CT and Ex-CT scans were within 1 level difference in 18 (35.3%) and 47 (92.2%) patients, respectively ( P < 0.001). The vertical angle of the RAV was significantly more likely to be smaller on In-CT than on Ex-CT ( P < 0.001).

CONCLUSIONS

RAV locations and angles change with respiratory motion. It is crucial to consider the respiratory phase of CT because it can enable a more accurate prediction of the location of the RAV during AVS.

Prevalence and Risk Factors for Secondary Hypertension in Young Adults

BACKGROUND

The prevalence of secondary causes of hypertension in young adults is unknown, and therefore, there is no consensus about the indication of screening of secondary hypertension (2HTN) in this population. The objective was to report the prevalence and the causes of 2HTN in young subjects.

METHODS

In this cross-sectional study, 2090 patients with confirmed hypertension aged 18 to 40 years with full workup for 2HTN screening were included. We assessed the prevalence of 2HTN and analyzed the factors associated.

RESULTS

Among 2090 patients, 619 (29.6%) had a 2HTN. The most frequent diagnoses of 2HTN in descending order were primary aldosteronism (n=339; 54.8%), renovascular hypertension (n=114; 18.4%), primary kidney disease (n=80; 12.9%), pheochromocytoma/functional paraganglioma (n=37; 5.9%), hypertension caused by drugs or substances (n=32; 6.0%), and other diagnoses (n=17; 2.7%). Patients with blood pressure <160/100 mm Hg did not have a lower prevalence of 2HTN regardless of the number of treatments. The prevalence of 2HTN was higher in the decade between 30 and 40 years of age than between 18 and 30 years of age (P=0.024). Female sex, hypokalemia, treatment with at least 2 medications, no familial history of hypertension, body mass index <25 kg/m², and diabetes were associated with a higher prevalence of 2HTN.

CONCLUSIONS

The prevalence of 2HTN is high among young patients with hypertension (29.6% in our cohort), regardless of age and blood pressure level. All patients with hypertension under 40 years of age should be screened for secondary causes.

Aldosterone in the brain and cognition: knowns and unknowns

Mineralocorticoid receptors are expressed in several structures of the central nervous system, and aldosterone levels can be measured in the brain, although in smaller amounts than in plasma. Nevertheless, these amounts appear to be sufficient to elicit substantial clinical effects. Primary aldosteronism, characterized by high levels of plasma aldosterone, is one of the most common causes of secondary hypertension. In this context, high aldosterone levels may have both indirect and direct effects on the brain with a negative impact on several cerebral functions. Thus, chronic aldosterone excess has been associated with symptoms of anxiety and depression - two clinical entities themselves associated with cognitive deficits. Today, there is an increasing number of reports on the influence of aldosterone on the brain, but there is also a significant amount of uncertainty, such as the role of high aldosterone levels on cognitive functions and decline independently of blood pressure. In this mini review, we discuss the known and unknowns of the impact of aldosterone on the brain putting emphasis on cognitive functions.

Genetic testing for familial hyperaldosteronism type 1 in Aotearoa/New Zealand

BACKGROUND

Primary aldosteronism (PA) is the most common secondary endocrine cause of hypertension with familial hyperaldosteronism type 1 (FH-1), a rare heritable subtype. Timely identification of FH-1 is important because of an increased risk of vascular events in affected individuals and because it provides the opportunity to guide appropriate treatment. Genetic testing is recommended if onset is at a young age (<20 years), there is a family history of PA or early cerebrovascular events occur.

AIMS

To assess national rates of testing for FH-1, whether this varied over time and by region.

METHODS

De-identified data were obtained on genetic testing performed for FH-1 from 1 April 2010 to 30 October 2023 (163 months) from the Canterbury Health Laboratories database, the sole national testing laboratory for FH-1.

RESULTS

A total of 147 tests were performed, of which 19 (12.9%) were positive. Eleven of the positive tests were requested by one region. Testing rates varied from 0.00 to 0.63 per 100 000 people per annum. Most tests were requested by endocrinology services. Testing increased over time from an average of 4.6 tests per annum in the first 5 years of the period studied to 17.7 tests in the most recent 5 years. Limitations include lack of ethnicity data, information on testing indications and testing rates for other familial PA subtypes.

CONCLUSIONS

Testing for FH-1 has increased over time but remains low. Testing for familial forms of PA should be considered in those in whom PA was diagnosed at a young age or with a suggestive family history.

Establishment of a scoring model for predicting clinical outcomes in patients with unilateral primary aldosteronism after superselective adrenal artery embolization

OBJECTIVE

Superselective adrenal arterial embolization (SAAE) is a potential alternative treatment for patients with unilateral primary aldosteronism (PA) who refuse unilateral adrenalectomy. Therefore, we aimed to establish a scoring model to differentiate between hypertensive remission after SAAE.

METHODS

This prospective cohort study involved 240 patients who underwent SAAE for unilateral PA. Patients were randomly divided into a model training set and a validation set at a ratio of 7:3. The clinical outcome was a response to hypertension remission, defined as complete, partial, or absent success at 6 months after SAAE. Multivariate logistic regression was performed to identify independent parameters and develop a nomogram to predict clinical outcomes after SAAE. The discrimination, calibration efficacy, and clinical utility of the predictive model were assessed.

RESULTS

Five independent predictors were identified: female sex, duration of hypertension, defined daily dose of antihypertensive medication, diabetes, and target organ damage. The above five independent predictors were put into a predictive model that was presented as a nomogram. Using bootstrapping for internal validation, the C-statistic for the predictive model was 0.866 (95% confidence interval [CI]: 0.834 to 0.898). In the validation cohort, the area under the curve (AUC) of the nomogram for predicting hypertension remission after SAAE was 0.809.

CONCLUSION

The present model is the first nomogram-based score that specifically predicts hypertension remission after SAAE in patients with unilateral PA using conventional parameters. This is an effective risk stratification tool that can be used by clinicians for timely and tailored preoperative risk discussions.

Executive summary of the Spanish consensus for the diagnosis, management, and follow-up of primary hyperaldosteronism

Primary hyperaldosteronism (PH) is the most common cause of secondary hypertension (HTN) and is associated with a higher cardiometabolic risk than essential HTN. Nevertheless, PH remains clearly underdiagnosed. An early diagnosis and adequate treatment of this disease are essential to reduce the cardiometabolic morbimortality associated with aldosterone excess. PH follow-up is equally essential; however, there is little consensus on how it should be performed, being a topic rarely mentioned by the different clinical practice guidelines. The aim of this executive summary is to summarize the recommendations made in the Spanish consensus of PH for the diagnosis, management, and follow-up of these patients. The Spanish consensus was reached from a multidisciplinary perspective through a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Society of Cardiology (SEC), the Spanish Society of Nephrology (SEN), the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Radiology (SERAM), the Spanish Society of Vascular and Interventional Radiology (SERVEI), the Spanish Society of Laboratory Medicine (SEQC(ML)), the Spanish Society of Anatomic-Pathology (EAP), and the Spanish Association of Surgeons (AEC).

Integration of two-dimensional echocardiography: A novel risk indicator for ST-segment elevation myocardial infarction

AIMS

We aim to integrate the parameters of two-dimensional (2D) echocardiography and identify the high-risk population for all-cause mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI).

METHODS

The study involved a retrospective cohort population with STEMI who were admitted to Yongchuan Hospital of Chongqing Medical University between January 2016 and January 2019. Baseline data were collected, including 2D echocardiography parameters and left ventricular ejection fraction (LVEF). The parameters of 2D echocardiography were subjected to cluster analysis. Logistic regression models were employed to assess univariate and multivariate adjusted odds ratios (ORs) of cluster information in relation to all-cause mortality. Four logistic regression models were generated, utilizing cluster information, clinical variables, clinical variables in conjunction with LVEF, and clinical variables in conjunction with LVEF and cluster information as predictive variables, respectively. The area under the curve (AUC) were utilized to evaluate the incremental risk stratification value of cluster information.

RESULTS

The study included 633 participants with 28.8% female, a mean age of 65.68 ± 11.98 years. Over the course of a 3-year follow-up period, 108 (17.1%) patients experienced all-cause mortality. Utilizing cluster analysis of 2D echocardiography parameters, the patients were categorized into two distinct clusters, with statistically significant differences observed in most clinical variables, echocardiography, and survival outcomes between the clusters. Multivariate regression analysis revealed that cluster information was independently associated with the risk of all-cause mortality with adjusted OR 7.33 (95% confidence interval [CI] 3.99-14.06, P < 0.001). The inclusion of LVEF enhanced the predictive capacity of the model utilized with clinical variables with AUC 0.848 (95% CI 0.809-0.888) versus AUC 0.872 (95% CI 0.836-0.908) (P < 0.001), and the addition of cluster information further improved its predictive performance with AUC 0.906 (95% CI 0.878-0.934, P < 0.001). This cluster analysis was translated into a free available online calculator (https://app-for-mortality-prediction-cluster.streamlit.app/).

CONCLUSIONS

The 2D echocardiographic diagnostic information based on cluster analysis had good prognostic value for STEMI population, which was helpful for risk stratification and individualized intervention.

Primary aldosteronism prevalence enhanced by strict adherence to 2016 Endocrine Society guidelines: insights from an endocrine hypertension unit

INTRODUCTION

Primary aldosteronism is the most frequent cause of hypertension although is undetected. The 2016 Endocrine Society guidelines (2016-ESG) recommendations for primary aldosteronism detection are unfulfilled. We aimed to ascertain the prevalence of primary aldosteronism, following the screening criteria endorsed by the 2016-ESG.

METHODS

All adult patients tested for primary aldosteronism at an endocrine hypertension unit of a tertiary hospital during 2021-2023 were studied. Primary aldosteronism investigation was performed when at least one reason for its screening based on 2016-ESG was detected. When screening was positive, confirmatory tests were executed. Rates and diagnostic accuracy of the reasons for primary aldosteronism screening were analyzed.

RESULTS

Two hundred and sixty-five patients were included. Mean age was 55 ± 14 years, 124 of 265 (46.8%) were women, 24.6% had hypokalemia, and 16% adrenal incidentaloma(s) as indication for screening. Primary aldosteronism was diagnosed in 122 of 265 (46%). The presence of each reason for primary aldosteronism screening increased the probability of primary aldosteronism in 2.2-fold [95% confidence interval (CI): 1.63 to 2.97; P < 0.001]. The most frequent reason for primary aldosteronism screening was a blood pressure at least 150/100 mmHg on three measurements on different days, and had a sensitivity of 95%. Hypertension with spontaneous or diuretic-induced hypokalemia was the most specific reason (87.5%) but was not frequent. Adrenal incidentaloma(s) was not associated with primary aldosteronism diagnosis.

CONCLUSION

Primary aldosteronism prevalence is markedly high when the 2016-ESG recommendations are rigorously implemented. The greater the number of indications for primary aldosteronism investigation, the higher its prevalence. Further studies are needed to corroborate this observed primary aldosteronism prevalence.

Screening and treatment of endocrine hypertension focusing on adrenal gland disorders: a narrative review

Most cases of high blood pressure have no identifiable cause, termed essential hypertension; however, in approximately 15% of cases, hypertension occurs due to secondary causes. Primary aldosteronism (PA) and pheochromocytoma and paraganglioma (PPGL) are representative endocrine hypertensive diseases. The differentiation of endocrine hypertension provides an opportunity to cure and prevent target organ damage. PA is the most common cause of secondary hypertension, which significantly increases the risk of cardiovascular disease compared to essential hypertension; thus, patients with clinical manifestations suggestive of secondary hypertension should be screened for PA. PPGL are rare but can be fatal when misdiagnosed. PPGL are the most common hereditary endocrine tumors; therefore, genetic testing using next-generation sequencing panels is recommended. Herein, we aimed to summarize the characteristic clinical symptoms of PA and PPGL and when and how diagnostic tests and treatment strategies should be performed.

Cutoff Values of Aldosterone and the Aldosterone-Renin Ratio for Predicting Primary Aldosteronism in Patients with Resistant Hypertension: A Real-Life Study

Primary aldosteronism (PA) is commonly associated with resistant hypertension. Biochemical tests can be clinically useful in the screening and diagnosis of primary aldosteronism. This study aimed to identify the cutoff values of aldosterone levels (A) and the aldosterone-renin ratio (ARR) for an accurate prediction of PA in patients with apparent resistant hypertension in a real-life scenario. This database-based study included a historical cohort of male and female patients with apparent resistant hypertension, aged 18 years or older and surveyed for PA in a specialized center from 2008 to 2018. Aldosterone and plasma renin activity (PRA) or the plasma renin concentration (PRC) were measured in the treated hypertensive patients. The patients with positive screening results were subsequently referred to the endocrinology department for confirmatory tests. The patients with confirmed PA were included in the case group, and the others remained as controls. Receiver-operating characteristic (ROC) curves were used to identify the cutoff points for aldosterone and the ARR, thereby analyzing their sensitivity and specificity for confirmed PA. Among the 3464 patients (59 ± 13 years old, 41% male) who had apparent resistance hypertension screened, PA was confirmed in 276 individuals (8%). A ≥ 16.95 ng/dL (95% CI: 0.908-0.933) had an odds ratio of 6.24 for PA, while A/PRA ≥ 29.88 (95% CI: 0.942-0.984) or an A/PRC ≥ 2.44 (95% CI: 0.978-0.990) had an odds ratio of 216.17 for PA diagnoses. Our findings suggest that a positive PA screening with aldosterone ≥ 17 ng/dL associated with A/PRA ≥ 29.88 or an A/PRC ratio of ≥2.44 should be sufficient to confirm the diagnosis of PA without confirmatory testing.

Influence of sex and functional status on the value of serum steroid profiling in discriminating adrenocortical carcinoma from adrenocortical adenoma

Background

It is challenging for clinicians to distinguish adrenocortical carcinoma (ACC) from benign adrenocortical adenomas (ACA) in their early stages. This study explored the value of serum steroid profiling as a complementary biomarker for malignancy diagnosis of ACC other than diameter and explored the influence of sex and functional status.

Methods

In this retrospective study, a matched cohort of patients diagnosed with either ACC or ACA based on histopathology was meticulously paired in a 1:1 ratio according to sex, age, and functional status. Eight serum steroids including 11-deoxycortisol, 11-deoxycorticosterone, progesterone, androstenedione, dehydroepiandrosterone (DHEA), dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone, and estradiol, were quantified by liquid chromatography tandem mass spectrometry. We conducted a comparative analysis of the clinical characteristics and serum steroid profiles of patients with ACC and ACA, with further subgroup analysis.

Results

The study included 31 patients with ACC and 31 matched patients with ACA. Patients with ACC exhibited significantly larger tumor diameters, lower body mass index (BMI), and higher levels of 11-deoxycortisol, progesterone, and androstenedione than those with ACA. 11-deoxycortisol was the only valuable index for discriminating ACC from ACA, regardless of functional status and sex. Progesterone, DHEA, and DHEAS levels were higher in the functional ACC group than in the non-functional ACC group. Female ACC patients, especially in postmenopausal female exhibited higher levels of androstenedione than male patients. The area under the curve of tumor diameter, 11-deoxycortisol, and BMI was 0.947 (95% CI 0.889-1.000), with a sensitivity of 96.8% and specificity of 90.3%.

Conclusion

Serum steroid profiling serves as a helpful discriminative marker for ACC and ACA, with 11-deoxycortisol being the most valuable marker. For other steroid hormones, consideration of sex differences and functional status is crucial.

[131I]6ß-Iodomethyl-19-norcholesterol SPECT/CT for the Lateralization of Mineralocorticoid Overproduction in Primary Aldosteronism

Primary: aldosteronism is a frequent cause of secondary hypertension. With access to specialized care, an increasing number of patients with aldosteronism are being identified. Primary aldosteronism is treatable by adrenal surgery if aldosterone excess originates from one of the two, and not from both, adrenals. Bilateral hyperplasia requires lifelong mineralocorticoid receptor antagonist treatment. Up till now, adrenal venous sampling (AVS) has been widely used to distinguish between one-sided and two-sided aldosterone overproduction and patient selection for surgery. AVS is an invasive technique, and the unsuccessful sampling of the right adrenal vein during AVS often prevents side comparison, making the AVS procedure useless. Molecular imaging using [131I]6ß-iodomethyl-19-norcholesterol with SPECT CT imaging (SPECT/CT) may be a potential alternative.

METHODS

In 42 consecutive patients with confirmed primary aldosteronism, molecular imaging has been performed. After dexamethasone suppression of the non-affected adrenal tissue, 37 MBq [131I]6ß-iodomethyl-19-norcholesterol was injected i.v., and SPECT/CT images were taken 7 days later. Based on the visual evaluation of the images by two nuclear medicine specialists, patients with one-sided tracer accumulation underwent adrenalectomy. To identify a SPECT/CT parameter that best characterizes the side difference, the maximum counts and the mean counts of spherical VOIs were analyzed.

RESULTS

Of the 42 patients, 24 had one-sided aldosterone overproduction by SPECT/CT. After surgical removal of the involved adrenal, all 24 patients with SPECT/CT-identified unilateral aldosteronism achieved biochemical cure, defined as a normalized potassium level combined with an aldosterone-to-renin ratio ≤ 30. To identify the best measurable parameter of SPECT/CT side difference, the mean counts and maximum counts of a series of spherical VOIs of different diameters were analyzed. The ratio of the mean counts of 3 cm spherical VOIs of the right and left adrenal regions (lateralization index) was the best discriminator; a ratio of ≥1.29 was characteristic of one-sided disease, without overlap between the one-sided and two-sided patient groups.

CONCLUSIONS

[131I]6ß-iodomethyl-19-norcholesterol SPECT/CT with a count-based image interpretation and side-ratio calculation may be an equipollent non-invasive substitute for adrenal venous sampling in the lateralization of mineralocorticoid overproduction. It reliably identifies unilateral disease and facilitates patients' selection for surgical intervention. If confirmed by others, this functional imaging may replace AVS when lateralization is required for management decisions in primary aldosteronism.

Efficacy and safety of radiofrequency ablation and laparoscopic adrenalectomy for primary aldosteronism: a meta‑analysis

OBJECTIVE

To compare the efficacy (including blood pressure, medication reduction, serum potassium, and clinical success) and safety parameters (including operative time, length of hospital stay, blood loss, hypertension crisis rate, and complication rate) of radiofrequency ablation (RFA) and laparoscopic adrenalectomy (LA) in the treatment of primary aldosteronism (PA).

METHODS

Literature search was performed on PubMed, EMBASE, The Cochrane Library (Issue 8, 2023), Web of Science, China National Knowledge Infrastructure, and Wanfang from inception to August 2023. Study selection, data extraction, and risk of bias assessment were performed by two independent reviewers. Quality assessment was conducted using the Newcastle-Ottawa scale. The Stata 12.0 software was used for statistical analyses. Pooled odds ratios (OR) with corresponding 95% confidence interval (CI) were calculated for categorical outcomes, while mean difference (MD) with corresponding 95% CI were calculated for continuous outcomes.

RESULTS

A total of 5 studies involving 204 patients (LA, n = 127; and RAF, n = 77) were included. LA had better diastolic blood pressure control than RFA (WMD = 5.19; 95% CI 0.96-9.43); however, the RFA demonstrated better shorter operative time (WMD = - 57.99; 95% CI - 116.54 to 0.57), and shorter length of hospital stay (OR - 1.6; 95% CI - 2.37 to - 0.83) compared to LA. All remaining parameters were comparable between the interventions.

CONCLUSION

While grossly comparable in efficacy as treatment options for PA, RFA may allow for shorter operative time and hospital stay, less intraoperative blood loss, and lower hospitalization costs. However, LA has better diastolic blood pressure control. Even so, we still need larger prospective studies, specifically with comparative hypertension response (short and long term) and number of post-procedural antihypertensive medication requirement.

Clinical prediction model for primary aldosteronism subtyping and special focus on adrenal volumetric assessment

PURPOSE

Our aim was to develop a prediction model based on a simple score with clinical, laboratory, and imaging findings for the subtype diagnosis of primary aldosteronism (PA). The contribution of adrenal volumetric assessment to PA subtyping was also investigated.

METHODS

Thirty-five patients with adequate cannulation in adrenal venous sampling (AVS) were included. Laboratory data, the saline infusion test (SIT), and the AVS results of patients with PA were retrospectively evaluated. Volumetric assessment was performed using magnetic resonance imaging (MRI) and the ratio of adrenal volumes was calculated after adjusting for gender- and side-specific mean reference values of both adrenal glands.

RESULTS

The AVS was consistent with unilateral PA in 49% and bilateral in 51% of the patients. Hypertension as a reason for work-up, the highest aldosterone/lowest potassium value higher than 12, the percentage of plasma aldosterone concentration (PAC) reduction after SIT by equal or less than 43.5%, the use of oral potassium replacement, unilateral disease at pre-AVS imaging, and a ratio of adjusted adrenal volumes equal to or below 1.7 were indicative of unilateral disease in univariate logistic regression analysis concerning the distinction of PA subtyping (p < 0.05). Multivariate logistic regression analysis also revealed that adrenal volumetric assessment has an impact on PA subtyping (p < 0.05). In the prediction model, when each of the six parameters that were significant in the univariate logistic regression analysis was assigned one point, < 4 predicted bilateral PA, whereas ≥ 4 predicted unilateral PA (AUC:0.92, p < 0.001).

CONCLUSION

This prediction model before AVS may serve as a convenient and practical approach, while an adjusted adrenal volumetric assessment can make a positive contribution to PA subtyping.

Variable effect of the post-partum menstrual cycle on aldosterone and renin in women with recent preeclampsia

The purpose of the present study is to identify the impact of the postpartum menstrual cycle on aldosterone, renin, and their ratio of women with and without a preeclamptic pregnancy in the past. To this end, we analysed the data from 59 women with a history of preeclampsia and 39 healthy parous controls. Five to seven months post-partum, we measured aldosterone, renin, and the aldosterone-to-renin ratio during both the follicular and the luteal phase of the menstrual cycle. All measurements were taken in the supine position in the morning. Patients had maintained a standardized sodium diet in the week prior to the measurements. Our results show that in both post-partum women with recent preeclampsia and controls, average levels of renin and aldosterone are significantly elevated in the luteal phase as compared to the follicular phase. The aldosterone-to-renin ratio does not differ between the two phases in either group. Compared to controls, women with recent preeclampsia have significantly lower levels of renin, aldosterone, and aldosterone-to-renin ratio in the follicular phase. This remained consistent in the luteal phase, except for renin. A close correlation existed between the luteal and follicular aldosterone-to-renin ratio in the control group but not in the preeclampsia group. We conclude that both renin and aldosterone are significantly affected by the menstrual cycle whereas the resulting aldosterone-to-renin ratio is not. Post-partum women with recent preeclampsia tend to have lower values for aldosterone and the aldosterone-to-renin ratio than controls.

Usefulness of the Upright Posture Test in the Diagnosis of Primary Aldosteronism

Objective

To assess the usefulness of the upright posture stimulation test (UPT) in the confirmation of primary aldosteronism (PA) in patients in whom saline tests (ST) were inconclusive.

Methods

One hundred eighty-seven adult patients with possible PA were retrospectively included and compared to 25 control subjects. Blood samples were obtained after a 1-hour supine posture and during 2 hours of ambulation. An increase in plasma aldosterone concentration (PAC) ≥ 50% with a suppressed renin (≤10.1 ng/L; ≤1 ng/mL/hour) and a cortisol increase ≤50% were considered abnormal.

Results

PA patients had higher basal PAC and lower basal direct renin concentration (DRC) (P < .0001) and a higher maximal PAC (P = .0025) and lower maximal DRC (DRCmax) (P < .0001) during UPT compared to controls. PA was confirmed in 145 patients (77.5%), based on either oral/IV ST or UPT. DRCmax ≤12 ng/L during UPT was a predictor of PA (receiver operating characteristic curve sensitivity 93.8%, specificity 88%), and 95.6% of PA patients increased PAC ≥50% on UPT (median 222.2%), while renin remained suppressed. All 41 PA patients with false-negative IV ST (PAC < 162 pmol/L) and 88.9% with borderline response (162-240 pmol/L) had a DRCmax ≤12, while, respectively, 97.6% and 100% increased aldosterone by ≥50%. Similar responses to UPT were found in lateralized (28/63) and bilateral PA source (35/63). PA diagnosis increased from 23.6% to 88.8% using UPT results instead of IV ST and were confirmed at pathology and clinical outcome after adrenalectomy (n = 22).

Conclusion

UPT can be useful to confirm PA, particularly in patients with suspected false-negative ST.

Safety and efficacy of bilateral superselective adrenal arterial embolization for treatment of idiopathic hyperaldosteronism: a prospective single-center study

OBJECTIVE

This study aimed to assess the efficacy and safety of bilateral superselective adrenal arterial embolization (SAAE) in patients with bilateral idiopathic hyperaldosteronism (IHA), a subtype of PA.

METHODS

Ninety-eight patients with bilateral IHA underwent bilateral SAAE between August 2022 and August 2023. Sixty-eight patients were followed up for up to 12 months. The study outcomes were evaluated using the criteria provided by the Primary Aldosteronism Surgical Outcome (PASO) guidelines.

RESULTS

The mean reductions in systolic and diastolic blood pressure were 27.4 ± 21.3 mmHg and 23.1 ± 17.4 mmHg, respectively (p < 0.001). The rates of clinical success and biochemical success after adrenal artery ablation were 63.2% (43/68) and 39.7% (27/68), respectively. Overall, there were significant reductions in daily defined doses (DDD), aldosterone/renin ratio (ARR), and plasma aldosterone levels (p < 0.001). Plasma renin levels increased by a mean value of 10.4 ± 39.0 pg/mL (p = 0.049), and potassium levels increased by 0.40 ± 0.63 mmol/L (p < 0.001). No significant adverse events were reported during SAAE or the follow-up period of up to one year. Additionally, no abnormalities were detected by adrenal 68Ga-Pentixafor PET/CT scans before or after SAAE.

CONCLUSION

Bilateral SAAE appears to lead to sustained improvements in blood pressure and biochemical parameters in patients with bilateral PA, with minimal adverse effects. This suggests that bilateral SAAE could serve as an effective alternative approach for treating bilateral IHA, potentially curing this condition.

The Spectrum of Dysregulated Aldosterone Production: An International Human Physiology Study

CONTEXT

Primary aldosteronism is a form of low-renin hypertension characterized by dysregulated aldosterone production.

OBJECTIVE

To investigate the contributions of renin-independent aldosteronism and ACTH-mediated aldosteronism in individuals with a low-renin phenotype representing the entire continuum of blood pressure.

DESIGN/PARTICIPANTS

Human physiology study of 348 participants with a low-renin phenotype with severe and/or resistant hypertension, hypertension with hypokalemia, elevated blood pressure and stage I/II hypertension, and normal blood pressure.

SETTING

4 international centers.

INTERVENTIONS/MAIN OUTCOME MEASURES

The saline suppression test (SST) to quantify the magnitude of renin-independent aldosteronism; dexamethasone suppression and ACTH-stimulation tests to quantify the magnitude of ACTH-mediated aldosteronism; adrenal venous sampling to determine lateralization.

RESULTS

There was a continuum of nonsuppressible and renin-independent aldosterone production following SST that paralleled the magnitude of the blood pressure continuum and transcended conventional diagnostic thresholds. In parallel, there was a full continuum of ACTH-mediated aldosteronism wherein post-SST aldosterone levels were strongly correlated with ACTH-stimulated aldosterone production (r = 0.75, P < .0001) and nonsuppressible aldosterone production postdexamethasone (r = 0.40, P < .0001). Beyond participants who met the criteria for primary aldosteronism (post-SST aldosterone of ≥10 ng/dL or ≥277 pmol/L), the continuum of nonsuppressible and renin-independent aldosterone production persisted below this diagnostic threshold, wherein 15% still had lateralizing aldosteronism amenable to surgical adrenalectomy and the remainder were treated with mineralocorticoid receptor antagonists.

CONCLUSION

In the context of a low-renin phenotype, there is a continuum of primary aldosteronism and dysregulated aldosterone production that is prominently influenced by ACTH. A large proportion of individuals with low renin may benefit from aldosterone-directed therapy.

Saline suppression testing-induced hypocalcemia and implications for clinical interpretations

BACKGROUND

Extracellular calcium critically regulates physiologic aldosterone production. Moreover, abnormal calcium flux and signaling are involved in the pathogenesis of the majority of primary aldosteronism cases.

METHODS

We investigated the influence of the saline suppression test (SST) on calcium homeostasis in prospectively recruited participants (n = 86).

RESULTS

During SST, 100% of participants had decreases in serum calcium, with 48% developing frank hypocalcemia. Serum calcium declined from 2.30 ± 0.08 mmol/L to 2.13 ± 0.08 mmol/L (P < .001) with parallel increases in parathyroid hormone from 6.06 ± 2.39 pmol/L to 8.13 ± 2.42 pmol/L (P < .001). In contrast, serum potassium and bicarbonate did not change, whereas eGFR increased and serum glucose decreased (P < .001). Lower body surface area (translating to greater effective circulating volume expansion during SST) was associated with greater reductions in (β = .33, P = .001), and absolutely lower, serum calcium levels (β = .25, P = .001). When evaluating clinically-relevant diagnostic thresholds, participants with post-SST aldosterone levels <138 pmol/L had lower post-SST calcium and 25-hydroxyvitamin D levels (P < .05), and higher post-SST parathyroid hormone levels (P < .05) compared with those with post-SST aldosterone levels >277 pmol/L.

CONCLUSION

SST uniformly decreases serum calcium, which is likely to be due to the combination of variable dilution, increased renal clearance, and vitamin D status. These acute reductions in bioavailable calcium are associated with lower post-SST aldosterone. Given the critical role of extracellular calcium in regulating aldosterone production, these findings warrant renewed inquiry into the validity of SST interpretations for excluding primary aldosteronism.

Diagnostic Accuracy of Aldosterone and Renin Measurement by Chemiluminescence for Screening of Patients with Primary Aldosteronism

Primary aldosteronism (PA) is the most common cause of endocrine arterial hypertension, and the suggested screening test for case detection is the aldosterone-to-renin ratio (ARR) or aldosterone-to-direct renin ratio (ADRR) based on radio-immunoassay (RIA) and chemiluminescence assay (CLIA), respectively. The objective of our study was to evaluate the reliability of CLIA for aldosterone and renin measurement and the diagnostic performance of ADRR. A prospective cohort of 1110 patients referred to a single laboratory medicine center underwent measurement of aldosterone and direct renin concentration (DRC) by CLIA and measurement of aldosterone and plasma renin activity (PRA) by RIA. Of 1110 patients, 640 obtained a final diagnosis of hypertension, and 90 of these patients were diagnosed with PA. Overall, between-method correlation was highly significant for aldosterone concentrations (R = 0.945, p < 0.001) and less strong but significant for DRC/PRA (R = 0.422, p < 0.001). Among hypertensive patients, in PA cases, the areas under the receiver operator characteristics (ROC) curves were 0.928 (95% confidence interval 0.904-0.954) for ADRR and 0.943 (95% confidence interval 0.920-0.966) for ARR and were comparable and not significantly different. The highest accuracy was obtained with an ADRR cut-off of 25 (ng/L)/(mIU/L), displaying a sensitivity of 91% and a specificity of 85%. The chemiluminescence assay for aldosterone and DRC is a reliable method for PA diagnosis compared to the classical RIA method.

Practical consensus for the treatment and follow-up of primary aldosteronism: a multidisciplinary consensus document

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension and is associated with a higher cardiometabolic risk than essential hypertension. The aim of this consensus is to provide practical clinical recommendations for its surgical and medical treatment, pathology study and biochemical and clinical follow-up, as well as for the approach in special situations like advanced age, pregnancy and chronic kidney disease, from a multidisciplinary perspective, in a nominal group consensus approach of experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology and Spanish Association of Surgeons (AEC).

Best Practice Alert to Promote Screening for Primary Aldosteronism Among People With Apparent Treatment-Resistant Hypertension

OBJECTIVE

Guidelines recommend screening all individuals with resistant hypertension for primary aldosteronism (PA) but less than 2% are screened. We aimed to develop a noninterruptive Best Practice Alert (BPA) to assess if its implementation in the electronic health record improved PA screening rates among individuals with apparent treatment-resistant hypertension (aTRH).

METHODS

We implemented a noninterruptive BPA on 9/17/2022 at our ambulatory primary care, endocrinology, nephrology, and cardiology clinics. We assessed clinical parameters of people with aTRH before (9/17/2021-9/16/2022) and after (9/17/2022-9/16/2023) the BPA was implemented. The noninterruptive BPA embedded with an order set identified people with aTRH and recommended screening for PA if it was not previously performed.

RESULTS

There were 10 944 and 11 463 people with aTRH who attended office visits during the 12 months before and after the BPA implementation, respectively. There were no statistically significant differences in median age (P = .096), sex (P = .577), race (P = .753), and ethnicity (P = .472) between the pre- and post-BPA implementation groups. There was a significant increase in PA screening orders placed (227 [2.1%] vs 476 [4.2%], P < .001) and PA screening labs performed (169 [1.5%] vs 382 [3.3, P < .001) after BPA implementation. PA screening tests were positive in 26% (44/169) and 23% (88/382) of people in the pre- and post-BPA groups, respectively (P = .447).

CONCLUSION

Implementation of a real-time electronic health record BPA doubled the screening rate for PA among people with aTRH; however, the overall screening rate was low.

Selective venous sampling for secondary hypertension

Selective venous sampling (SVS), an invasive radiographic procedure that depends on contrast media, holds a unique role in diagnosing and guiding the treatment of certain types of secondary hypertension, particularly in patients who may be candidates for curative surgery. The adrenal venous sampling (AVS), in particular, is established as the gold standard for localizing and subtyping primary aldosteronism (PA). Throughout decades of clinical practice, AVS could be applied not only to PA but also to other endocrine diseases, such as adrenal Cushing syndrome (ACS) and Pheochromocytomas (PCCs). Notably, the application of AVS in ACS and PCCs remains less recognized compared to PA, with the low success rate of catheterization, the controversy of results interpretation, and the absence of a standardized protocol. Additionally, the AVS procedure necessitates enhancements to boost its success rate, with several helpful but imperfect methods emerging, yet continued exploration remains essential. We also observed renal venous sampling (RVS), an operation akin to AVS in principle, serves as an effective means of diagnosing renin-dependent hypertension, aiding in the identification of precise sources of renin excess and helping the selection of surgical candidates with renin angiotensin aldosterone system (RAAS) abnormal activation. Nonetheless, further basic and clinical research is needed. Selective venous sampling (SVS) can be used in identifying cases of secondary hypertension that are curable by surgical intervention. Adrenal venous sampling (AVS) and aldosterone measurement for classificatory diagnosis of primary aldosteronism (PA) are established worldwide. While its primary application is for PA, AVS also holds the potential for diagnosing other endocrine disorders, including adrenal Cushing's syndrome (ACS) and pheochromocytomas (PCCs) through the measurements of cortisol and catecholamine respectively. In addition, renal venous sampling and renin measurement can help to diagnose renovascular hypertension and reninoma.

Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism

Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).