Key result
A clinical decision tool based on seven variables reliably predicted primary aldosteronism with a c-statistic of 0.77, potentially sparing 8-32% of patients from intensive diagnostic testing.
Why the study?
Satisfactory tools to identify low-risk patients who can be spared intensive diagnostic testing for primary aldosteronism are lacking.
Does a clinical decision tool based on seven clinical variables reliably predict the probability of primary aldosteronism in patients with difficult-to-control hypertension?
Cross-Sectional (n=824)
No
Does a clinical decision tool based on seven clinical variables reliably predict the probability of primary aldosteronism in patients with difficult-to-control hypertension?
Effect estimate: c-statistic 0.77 (95% CI 0.70-0.83)
A clinical decision tool using seven routine clinical variables can reliably identify patients with difficult-to-control hypertension who have a low probability of primary aldosteronism, potentially sparing 8-32% from intensive diagnostic testing.
May limit unnecessary PA testing in low-probability resistant hypertension; hypothesis-generating and requires prospective validation.
BACKGROUND: Satisfactory tools to preclude low-risk patients from intensive diagnostic testing for primary aldosteronism (PA) are lacking. Therefore, we aimed to develop a decision tool to determine which patients with difficult-to-control hypertension have a low probability of PA, thereby limiting the exposure to invasive testing while at the same time increasing the efficiency of testing in the remaining patients. METHODS: Data from consecutive patients with difficult-to-control hypertension, analysed through a standardized diagnostic protocol between January 2010 and October 2017 (n = 824), were included in this cross-sectional study. PA was diagnosed by a combined approach: 1) elevated aldosterone-to-renin ratio (> 5.0 pmol/fmol/s), confirmed with 2) non-suppressible aldosterone after standardized saline infusion (≥280 pmol/L). Multivariable logistic regression analyses including seven pre-specified clinical variables (age, systolic blood pressure, serum potassium, potassium supplementation, serum sodium, eGFR and HbA1c) was performed. After correction for optimism, test reliability, discriminative performance and test characteristics were determined. RESULTS: PA was diagnosed in 40 (4.9%) of 824 patients. Predicted probabilities of PA agreed well with observed frequencies and the c-statistic was 0.77 (95% confidence interval (95%CI) 0.70-0.83). Predicted probability cut-off values of 1.0-2.5% prevented unnecessary testing in 8-32% of the patients with difficult-to-control hypertension, carrying sensitivities of 0.98 (95%CI 0.96-0.99) and 0.92 (0.83-0.97), and negative predictive values of 0.99 (0.98-1.00) and 0.99 (0.97-0.99). CONCLUSIONS: With a decision tool, based on seven easy-to-measure clinical variables, patients with a low probability of PA can be reliably selected and a considerable proportion of patients with difficult-to-control hypertension can be spared intensive diagnostic testing.
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Kleef et al. (2020) conducted a cross-sectional in Difficult-to-control hypertension (n=824). Clinical decision tool (7 clinical variables) vs. Standard diagnostic testing was evaluated on Discriminative performance (c-statistic) for predicting primary aldosteronism (c-statistic 0.77, 95% CI 0.70-0.83). A clinical decision tool based on seven variables reliably predicted primary aldosteronism with a c-statistic of 0.77, potentially sparing 8-32% of patients from intensive diagnostic testing.
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