A detour guide to the Endocrine Society Clinical Practice Guideline on case detection, diagnosis and treatment of patients with primary aldosteronism

The Endocrine Society (USA) commissions clinical practice guidelines that address topics of major interest to the endocrine community and for which international consensus is urgently needed. As a reflection of the important contributions of European endocrinologists to the field, the Endocrine Society Clinical Guidelines Subcommittee has selected more and more European experts to join their American colleagues and help compiling and reviewing the guidelines before they are issued. However, a mid-term goal of transatlantic collaboration would certainly be the joint release of guidelines that appear concurrently in the Journal of Clinical Endocrinology & Metabolism and the European Journal of Endocrinology. Until this is achieved, we have actually decided to release a series of invited ‘European perspective’ commentaries on recently published guidelines and in this issue we will make a start with this commentary on the Clinical Practice Guideline on diagnosis and treatment of primary aldosteronism (1). Why do we need a clinical practice guideline on primary aldosteronism? Usually guidelines are needed when there have been important changes, primarily in the way we perceive the significance of a disease or when research has gained novel insights into pathogenesis and opens up new options for treatment. Primary aldosteronism has made it into the headlines over the last few years mainly due to the notion that it might be more frequent than previously assumed, possibly affecting up to 10% of all hypertensive patients (2, 3), with a recent large European trial reporting a prevalence of 4.8% (4). Thus, previous diagnosis rates would not reflect the entirety of a very rare disease but perhaps only the ‘tip of iceberg’, with many others also affected, but currently undiagnosed. With this perceived paradigm change came a change in attitude towards screening for primary aldosteronism. While we previously aimed to establish this diagnosis mainly in patients presenting with hypokalaemic hypertension, more and more physicians took to actively screening their hypertensive patients for the presence of primary hyperaldosteronism. However, given that in western countries currently about 10% of the population suffers from hypertension, these changes in diagnostic strategy represent a significant risk for our health care systems, potentially generating huge costs with insufficiently assessed gain. Thus, a level-headed look at our management strategy for primary hyperaldosteronism, based on systematic review of available evidence was urgently needed, and this is exactly what these guidelines set out to achieve.