From the Guidelines
A patient with suspected primary aldosteronism should undergo screening with the aldosterone-to-renin ratio (ARR) test, and if positive, confirmatory testing with a saline suppression test or oral salt-loading test should be performed, as recommended by the 2024 ESC guidelines 1.
Primary Aldosteronism HPI
The patient's history of presentation (HPI) for primary aldosteronism should include:
- A detailed history of hypertension, including the duration, severity, and response to treatment
- Symptoms such as fatigue, muscle weakness, and headaches
- History of hypokalemia, either spontaneous or diuretic-induced
- Family history of early-onset hypertension or stroke
- History of obstructive sleep apnea or other sleep disorders
- Medication history, including use of antihypertensive medications, diuretics, and other medications that may affect blood pressure or potassium levels
Clinical Indications
Clinical indications for primary aldosteronism include:
- Resistant hypertension
- Hypertension with hypokalemia
- Hypertension and muscle cramps or weakness
- Hypertension and incidentally discovered adrenal mass
- Hypertension and obstructive sleep apnea
- Hypertension and family history of early-onset hypertension or stroke
Physical Examination
The physical examination should include:
- Blood pressure measurement
- Orthostatic vital signs
- Examination for signs of hypokalemia, such as muscle weakness or arrhythmias
- Examination for signs of adrenal insufficiency, such as skin hyperpigmentation
Screening Tests
Screening tests for primary aldosteronism include:
- Plasma aldosterone/renin ratio under standardized conditions
- Oral sodium loading test or IV saline infusion test with plasma aldosterone measurement
Confirmatory Tests
Confirmatory tests for primary aldosteronism include:
- Saline suppression test
- Oral salt-loading test
- Adrenal imaging, such as CT or MRI scan, to determine the presence of an adrenal mass or hyperplasia
- Adrenal venous sampling to determine the source of excess aldosterone production
Management
Management of primary aldosteronism depends on the subtype and severity of the disease, and may include:
- Surgical removal of the offending adrenal gland for unilateral primary aldosteronism
- Medical treatment with mineralocorticoid receptor antagonists, such as spironolactone or eplerenone, for bilateral primary aldosteronism or unilateral primary aldosteronism that is not amenable to surgery.
From the FDA Drug Label
Spironolactone tablets are indicated in the following settings: Short-term preoperative treatment of patients with primary hyperaldosteronism. Long-term maintenance therapy for patients with discrete aldosterone-producing adrenal adenomas who are not candidates for surgery Long-term maintenance therapy for patients with bilateral micro or macronodular adrenal hyperplasia (idiopathic hyperaldosteronism).
The patient's History of Present Illness (HPI) for primary aldosteronism may include:
- Hypertension: The patient may have a history of uncontrolled high blood pressure.
- Hypokalemia: The patient may have a history of low potassium levels.
- Metabolic alkalosis: The patient may have a history of elevated blood pH.
- Edema: The patient may have a history of swelling in the legs, ankles, or feet. The patient may also have a family history of primary aldosteronism or other endocrine disorders. 2
From the Research
Primary Aldosteronism HPI
The following are key points to consider when creating a primary aldosteronism History of Present Illness (HPI):
- Hypertension: Primary aldosteronism is a common cause of secondary hypertension, particularly in patients with resistant hypertension 3, 4, 5
- Resistant Hypertension: Patients with resistant hypertension should be screened for primary aldosteronism, as it is a common underlying cause 3, 5
- Family History: A family history of primary aldosteronism, stroke at a young age, or other comorbidities such as sleep apnea should raise suspicion for primary aldosteronism 3, 6
- Hypokalemia: Patients with hypokalemia, particularly those with resistant hypokalemia, should be evaluated for primary aldosteronism 3, 6
- Adrenal Incidentaloma: The presence of an adrenal incidentaloma should prompt an evaluation for primary aldosteronism 6
- Symptoms: While primary aldosteronism is often asymptomatic, patients may present with symptoms such as headache, fatigue, or palpitations due to hypokalemia or hypertension 6
Diagnostic Considerations
- Aldosterone-Renin Ratio: An elevated aldosterone-renin ratio is a key diagnostic criterion for primary aldosteronism 3, 4
- Confirmatory Testing: Confirmatory tests such as the captopril challenge, oral or intravenous salt loading, or fludrocortisone suppression should be performed to confirm the diagnosis 3, 4
- Imaging: Adrenal computed tomography and adrenal vein sampling may be necessary to differentiate between unilateral and bilateral adrenal production of aldosterone 3, 4