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Primary aldosteronism (PA) affects 5-10% of hypertension patients and doubles cardiovascular risk. Screening with the aldosterone to renin ratio (ARR) and confirmatory tests is crucial for timely treatment and improved outcomes.

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Area of Science:

  • Endocrinology
  • Cardiovascular Medicine
  • Hypertension Management

Background:

  • Primary aldosteronism (PA) is a significant contributor to hypertension, presenting a doubled cardiovascular risk compared to essential hypertension.
  • Current screening involves the plasma aldosterone to renin ratio (ARR) and subsequent confirmatory tests, with unilateral disease often due to adenomas and bilateral disease termed idiopathic hyperaldosteronism (IHA).

Purpose of the Study:

  • To highlight the underdiagnosis of PA and advocate for expanded screening protocols.
  • To discuss current diagnostic and treatment strategies for PA and propose future advancements.

Main Methods:

  • Review of current diagnostic pathways for PA, including ARR, confirmatory tests, imaging, and adrenal venous sampling (AVS).
  • Discussion of treatment modalities for unilateral and bilateral PA, including surgery and mineralocorticoid receptor antagonists (MRAs).

Main Results:

  • PA is currently underdiagnosed, potentially affecting up to 50% of individuals with "essential" hypertension.
  • Surgical intervention for unilateral PA can normalize aldosterone levels and reduce blood pressure in about half of patients.
  • Medical management for bilateral PA involves MRAs, with newer, more selective agents in development.

Conclusions:

  • Expanded screening using a modified ARR with 24-h urinary aldosterone is recommended for all hypertensive individuals.
  • Adrenal venous sampling (AVS) may be increasingly replaced by advanced plasma steroid assays for differentiating PA subtypes.
  • Optimizing current MRA dosages and developing next-generation MRAs are key to improving PA management and patient compliance.