Key result
Pre-washout primary aldosteronism screening on DHP-CCBs misses ~45% of diagnoses using standard criteria.
Why the study?
To preliminarily investigate the feasibility of implementing primary aldosteronism screening without discontinuing dihydropyridine calcium channel blockers.
Does primary aldosteronism screening before washout of DHP-CCB monotherapy accurately detect primary aldosteronism in patients with secondary hypertension?
Cohort (n=198)
No
Does primary aldosteronism screening before washout of DHP-CCB monotherapy accurately detect primary aldosteronism in patients with secondary hypertension?
Effect estimate: AUROC 0.88 (95% CI 0.83-0.92)
Screening for primary aldosteronism before washing out DHP-CCBs using standard criteria leads to an unacceptably high missed diagnosis rate (45.2%), suggesting these drugs should be discontinued prior to testing unless lower ARR thresholds are validated.
Standard pre-washout screening may miss primary aldosteronism; leaves open whether adjusted ARR thresholds improve detection without washout.
This retrospective cohort study preliminarily investigated the feasibility of implementing primary aldosteronism (PA) screening without discontinuing dihydropyridine calcium channel blockers (DHP-CCBs). We screened all patients undergoing diagnostic testing for secondary hypertension from January 2017 to May 2022 at authors' center. For inclusion, patients must be on DHP-CCBs monotherapy for hypertension. Aldosterone and renin concentration were measured pre- and post-washout. Confirmatory tests were conducted in patients with positive screen [combination of ARR >2.5 (ng/dL)/(μIU/mL), aldosterone ≥10 ng/dL, and renin ≤8.2 μIU/mL] after washout. The final analysis included a total of 198 patients (median age: 49.5 years and 117 men). Confirmatory tests identified PA in 31 (15.7%) patients. Aldosterone-to-renin ratio (ARR) increased in 158 (79.8%) patients after washout. In 168 patients with a negative pre-washout screen, 22 turned positive after washout, and 14 were diagnosed PA. Consequently, the missed diagnosis rate of PA was 45.2% (14/31) when using standard positive screen criteria before washout of DHP-CCBs monotherapy. Exploratory analysis indicated that a pre-washout ARR cutoff of >1.2 (ng/dL)/(μIU/mL) demonstrated 0.97 sensitivity and 0.75 specificity. In conclusions, caution is warranted when interpretating screening results from patients on DHP-CCBs monotherapy due to the potential risk of missed diagnosis. Preliminary data suggest that ARR ≤1.2 (ng/dL)/(μIU/mL) before washout may serve as a candidate threshold for excluding PA in these patients, though this observation remains a hypothesis-generating finding that requires further investigation.
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Liu et al. (2026) conducted a cohort in Secondary hypertension (screening for primary aldosteronism) (n=198). DHP-CCB monotherapy before washout vs. Post-washout screening was evaluated on Diagnostic accuracy (AUROC) of aldosterone-to-renin ratio (ARR) before washout to predict primary aldosteronism (AUROC 0.88, 95% CI 0.83-0.92). Screening for primary aldosteronism before washout of dihydropyridine calcium channel blockers using standard criteria resulted in a 45.2% missed diagnosis rate, whereas an exploratory pre-washout ARR cutoff >1.2 demonstrated 97% sensitivity.
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