Screen All With Hypertension for Primary Aldosteronism(ENDO 2025 presentation)
Screen All With Hypertension for Primary Aldosteronism(ENDO 2025 presentation)
Source: Medscape Medical News – Journal of Clinical Endocrinology and Metabolism
Date: July 14, 2025 (ENDO 2025 presentation)
1. Background
• Primary aldosteronism (PA): excess aldosterone secretion independent of renin, often due to adrenal adenoma or bilateral hyperplasia.
• Leads to hypertension, sodium retention, volume expansion, potassium loss, and direct cardiovascular/renal damage.
• Strongly linked to stroke, CAD, AF, HF, and CKD — risks are 2–3× higher compared to essential hypertension.
• PA is under-recognized and under-treated, with screening rates <2% even in resistant hypertension.
2. Key Prevalence Data
• 5.9% of primary care hypertensives.
• 16.2% of young adults (18–40 yrs).
• 28.1% of those with hypertension + hypokalemia.
• 42% with hypertension + AF.
• 11–19% with hypertension + type 2 diabetes.
3. Guideline Highlights (Endocrine Society, 2025)
Ten conditional recommendations (“we suggest”), endorsed by AHA, ESC, ISH, and others:
1. Screen all individuals with hypertension for PA.
2. Use aldosterone-to-renin ratio (ARR) with potassium measurement for interpretation.
3. MRAs (spironolactone preferred) are first-line medical therapy.
(used as long-term treatment unless surgery is possible; directly block aldosterone’s harmful effects).
4. Unilateral adrenalectomy for lateralizing PA in surgical candidates.
(done if only one adrenal gland is overproducing aldosterone and the patient is fit and willing for surgery → potential cure).
5. CT and adrenal venous sampling before surgery.
(CT detects adrenal nodules; venous sampling confirms which gland is dominant — right, left, or both).
6. Dose escalation of MRAs suggested if renin remains suppressed.
(if a patient is on spironolactone/eplerenone and blood tests still show low renin, increase the dose until renin rises, indicating adequate aldosterone blockade).
7. Dexamethasone suppression test in patients with adrenal adenoma.
(used when a CT shows an adrenal nodule to check if it also produces cortisol or other hormones — usually recommended in most PA patients with adrenal nodules, though individualized based on size and suspicion).
8. MRAs are preferred over epithelial sodium-channel blockers.
(spironolactone/eplerenone are first-line; amiloride or triamterene are second-choice only).
9. Minimal/no antihypertensive withdrawal before testing (simplified vs older guidelines).
(unlike old practice, most BP medicines can be continued; MRAs must be stopped before blood tests because they distort ARR results; once diagnosis is confirmed, MRAs are restarted as therapy).
10. Screen-positive patients may undergo aldosterone suppression testing if intermediate probability and surgery is considered.
(performed when ARR is positive but not clearly diagnostic, especially if surgery is planned).
4. Clinical Implications
• Universal screening could uncover many hidden cases, as already practiced in Japan, Australia, and China (cost-effective long-term).
• Simplified testing (no longer stopping all antihypertensives) lowers barriers.
• Broader screening may increase short-term healthcare costs, but reduces long-term cardiovascular/renal complications.
• Experts stress early detection to minimize end-organ damage and improve patient outcomes.
Takeaway
The Endocrine Society 2025 guideline recommends screening all patients with hypertension for primary aldosteronism using ARR and potassium levels.
• MRAs should be stopped before diagnostic testing, but remain the cornerstone of therapy afterward if surgery is not done.
• DST should be considered in PA patients with adrenal nodules on CT to exclude additional hormone secretion (e.g., cortisol).
Early diagnosis enables targeted treatment, reducing excess cardiovascular and renal risk.
