From the Guidelines
Hyperaldosteronism diagnosis should be approached through a systematic process starting with the measurement of the aldosterone-to-renin ratio (ARR) in a morning blood sample, followed by confirmatory testing if the ARR is elevated, as recommended by the most recent guidelines 1.
Diagnosis Process
The diagnosis of hyperaldosteronism involves several steps:
- Initial screening with the aldosterone-to-renin ratio (ARR) in a morning blood sample, with patients maintaining a normal sodium diet and discontinuing medications that affect the renin-angiotensin-aldosterone system for at least 2 weeks when possible.
- An elevated ARR (typically >20-30 ng/dL per ng/mL/hr) suggests hyperaldosteronism and requires confirmatory testing.
- Confirmatory testing may include the oral sodium loading test, saline infusion test, fludrocortisone suppression test, or captopril challenge test.
Importance of Early Diagnosis
Early diagnosis of hyperaldosteronism is crucial as it causes resistant hypertension and cardiovascular complications beyond what would be expected from hypertension alone, as highlighted in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.
Treatment Options
Treatment options for hyperaldosteronism depend on whether the condition is primary (adrenal-based) or secondary (extra-adrenal), with primary hyperaldosteronism often being treated with unilateral laparoscopic adrenalectomy or medical management with mineralocorticoid receptor antagonists (MRAs) such as spironolactone or eplerenone, as discussed in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 2, 3.
Key Considerations
Key considerations in the diagnosis and treatment of hyperaldosteronism include:
- The use of adrenal vein sampling to lateralize aldosterone production in patients considering surgical treatment.
- The importance of discontinuing medications that affect the renin-angiotensin-aldosterone system before testing.
- The need for careful evaluation of patients with suspected hyperaldosteronism to determine the underlying cause and appropriate treatment.
From the Research
Diagnosis of Hyperaldosteronism
- Hyperaldosteronism is a relatively common disorder that can lead to cardiovascular events, and patients suspected of having the condition should undergo initial screening and subsequent confirmatory testing to establish a biochemical diagnosis 4.
- The aldosterone-to-renin ratio (ARR) is the most practical and informative initial test for screening, and subsequent confirmatory tests include oral salt loading, saline infusion, captopril challenge, and fludrocortisone suppression test 5.
- Patients with a high pre-treatment aldosterone-to-renin ratio and a large post-treatment pulse pressure are at a higher risk for cardiovascular events, and early intervention may be important for preventing cardiovascular disease among patients with primary aldosteronism 6.
Diagnostic Tests and Procedures
- The identification of primary aldosteronism is based on the use of the plasma aldosterone level, plasma renin activity, and the aldosterone:renin ratio 7.
- Computed tomography scan of the adrenal glands and adrenal venous sampling are used to determine whether patients with confirmed primary aldosteronism have a disease that can be cured with surgery or whether it should be treated medically 8.
- Adrenal computed tomography/magnetic resonance imaging scans can often define a disease's subtype, but adrenal vein sampling may be necessary in some patients who are surgical candidates to determine lateralization 4.
Importance of Early Diagnosis and Treatment
- Primary aldosteronism is common and, when unrecognized, is associated with an increased incidence of adverse cardiovascular outcomes 7.
- Early diagnosis and treatment of primary aldosteronism can help prevent cardiovascular disease and reduce the risk of cardiovascular events 6.
- Clinicians should perform case detection testing for primary aldosteronism at least once in all patients with hypertension, and confirmatory testing is indicated in most patients with positive case detection testing results 8.