SFE/SFHTA/AFCE consensus on primary aldosteronism, part 4: Subtype diagnosis

Area of Science:

• Endocrinology
• Medical Diagnostics

Background:

• Primary aldosteronism (PA) diagnosis requires differentiating unilateral from bilateral adrenal aldosterone secretion.
• Surgical intervention, like adrenalectomy, is curative for hypertension and hypokalemia in unilateral PA cases.
• Genetic diagnosis is crucial for familial hyperaldosteronism types 1 and 3, which are non-surgical.

Framework:

• Adrenal CT or MRI and adrenal venous sampling are primary diagnostic tools for lateralized aldosterone secretion.
• Postural stimulation tests and (131)I-norcholesterol scintigraphy offer limited diagnostic utility.
• (11)C-metomidate PET is a potential future diagnostic modality.

Implementation:

• Adrenal CT or MRI is recommended for all PA patients to identify potential adrenocortical carcinoma or assess adrenal morphology.
• Imaging alone has limitations, including false positives in patients over 35 and false negatives for unilateral hyperplasia.
• Adrenal venous sampling, without ACTH stimulation, is suggested for surgical candidates over 35 to confirm unilateral hypersecretion.

Implications:

• Accurate lateralization diagnosis via adrenal venous sampling is critical for successful surgical outcomes in PA.
• Confirmation of unilateral PA through aldosterone/cortisol ratios (≥4-fold increase contralaterally) guides treatment decisions.
• This diagnostic approach optimizes patient selection for adrenalectomy, improving hypertension and hypokalemia management.