Rapid Diagnosis of Primary Aldosteronism
Oxymoron or One Small Step?
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See related article, pp 334–341
More than 60 years have passed since the first description of an aldosterone-producing adenoma (APA), and >10 years since robust prospective data established that these are a potentially curable cause of at least 5% of hypertension.1 Yet, there has been little progress in bridging the gulf between potential and actual cures. The senior author of the Endocrine Society’s revised guideline, John Funder, estimates that nowhere in the world are 1% of patients with primary aldosteronism (PA) ever diagnosed, let alone treated appropriately. In response to this deficit, the Endocrine Society has concentrated their firepower on public-health measures to increase awareness and diagnosis, recommending much wider criteria for biochemical testing of plasma renin and aldosterone, and referral to specialists of suspected PA.
The guideline illustrates the problem and the solution. On the one hand, PA has all the pre-requisites for modern precision medicine—rigorous, stratified diagnosis, leading to specific treatments and benefits. There is evidence that undiagnosed or uncontrolled PA is undesirable, causing increasingly resistant hypertension, and probably higher risk of cardiovascular morbidity. But the availability of a cheap medical antidote, spironolactone, and benign nature of APAs, create a hurdle to embarking on the expense and morbidity of investigations and surgery, which at best offers 30% to 60% likelihood of curing hypertension altogether.2
Because the options open to patients with PA mean that a high degree of certainty is sought for unilateral disease before committing to intervention, the seeds of a vicious circle are created in which the complexity of the steps in search of certainty raise further the bar to achieving this. To break …