Adrenal venous sampling: cosyntropin stimulation or not?

Area of Science:

• Endocrinology
• Hypertension Research
• Medical Diagnostics

Background:

• Primary aldosteronism (PA) is a prevalent cause of secondary hypertension, often overlooked, delaying effective treatment.
• Accurate diagnosis is vital for selecting curative therapies, necessitating differentiation between lateralized (adenoma) and bilateral (hyperplasia) forms.
• Current guidelines recommend adrenal vein sampling (AVS) for subtype differentiation, despite its technical difficulties and variable success rates.

Purpose of the Study:

• To debate the utility and impact of cosyntropin (synthetic ACTH) administration during adrenal vein sampling (AVS) for primary aldosteronism diagnosis.
• To present arguments for and against the use of cosyntropin as a stimulus in AVS procedures.
• To inform clinical practice regarding optimal AVS protocols for distinguishing aldosterone-producing adenoma from bilateral adrenal hyperplasia.

Main Methods:

• This article presents a debate reflecting diverse clinical practices and expert opinions on cosyntropin use during AVS.
• It reviews existing literature and clinical experiences supporting or refuting cosyntropin's role in maximizing adrenal secretion and improving AVS accuracy.
• The discussion addresses the technical challenges and potential benefits of cosyntropin stimulation in AVS.

Main Results:

• The use of cosyntropin during AVS is not universally standardized, with varying protocols across different centers.
• Evidence supporting cosyntropin's efficacy in improving AVS accuracy and differentiating PA subtypes remains debated.
• Arguments against its use include potential for increased procedural complexity and lack of definitive guideline recommendations.

Conclusions:

• The optimal use of cosyntropin during AVS for primary aldosteronism diagnosis requires further investigation and consensus.
• Clinicians face challenges in standardizing AVS protocols due to conflicting evidence and recommendations regarding cosyntropin stimulation.
• Further research is needed to establish clear guidelines on cosyntropin's role in improving the diagnostic yield of AVS for PA.