Electronic Health Record-Based Screening for Primary Aldosteronism in a Large Academic System

Primary aldosteronism (PA) remains an underdiagnosed cause of hypertension. Current practice is inconsistent with guideline recommendations for identifying high-risk patients. This study aims to evaluate PA screening and treatment across a large academic health system.

A retrospective cohort study was conducted on hypertensive patients (2017 to 2019) across ambulatory clinics, allowing for 5-year longitudinal follow-up. Patients meeting at least one Endocrine Society screening criterion were included: resistant hypertension, hypokalemia, adrenal mass, or obstructive sleep apnea. Screening was defined by collection of an aldosterone-renin ratio, with positivity defined by aldosterone-renin ratio ≥20 and aldosterone ≥10 ng/dl. Outcomes included screening rates, diagnostic yield, and subsequent treatment.

Of 40 865 hypertensive patients, 17 735 (43.4%) met ≥1 screening criterion. Only 736 (4.1%) were screened for PA, with rates varying by indication: 4.7% for resistant hypertension, 8.5% for hypokalemia, 26% for adrenal mass, and 1.6% for obstructive sleep apnea. Of those screened, 213 (28.9%) tested positive. Twenty-six patients (12%) underwent adrenalectomy, 81 (38%) received mineralocorticoid receptor antagonists, and 106 patients (50%) were untreated. Patients undergoing adrenalectomy trended towards fewer major cardiovascular events (2/70, 2.9%) compared with patients managed medically or untreated (25/303, 8.3%; P = .1). At 5 years, patients surgically or medially treated for PA were taking fewer antihypertensive medications, had lower mean systolic blood pressure and greater resolution of hypokalemia compared with untreated patients.

PA remains underdiagnosed and undertreated in high-risk populations. Interventions to improve systematic adherence to guideline-based screening may improve detection, management, and cardiovascular outcomes associated with untreated PA.