Key result
Clinicians screen only ~4% of high-risk hypertensive patients for primary aldosteronism.
Why the study?
Primary aldosteronism remains an underdiagnosed cause of hypertension with inconsistent adherence to guideline recommendations for screening high-risk patients.
Does guideline-based screening and treatment for primary aldosteronism improve detection and cardiovascular outcomes in high-risk hypertensive patients?
Cohort (n=40,865)
Does guideline-based screening and treatment for primary aldosteronism improve detection and cardiovascular outcomes in high-risk hypertensive patients?
Primary aldosteronism is severely under-screened and under-treated in high-risk hypertensive patients, highlighting a major gap in guideline-directed care that impacts cardiovascular outcomes.
Screening rates for primary aldosteronism remain low despite guidelines; leaves open whether targeted interventions improve detection and outcomes.
OBJECTIVES: Primary aldosteronism (PA) remains an underdiagnosed cause of hypertension. Current practice is inconsistent with guideline recommendations for identifying high-risk patients. This study aims to evaluate PA screening and treatment across a large academic health system. METHODS: A retrospective cohort study was conducted on hypertensive patients (2017 to 2019) across ambulatory clinics, allowing for 5-year longitudinal follow-up. Patients meeting at least one Endocrine Society screening criterion were included: resistant hypertension, hypokalemia, adrenal mass, or obstructive sleep apnea. Screening was defined by collection of an aldosterone-renin ratio, with positivity defined by aldosterone-renin ratio ≥20 and aldosterone ≥10 ng/dl. Outcomes included screening rates, diagnostic yield, and subsequent treatment. RESULTS: Of 40 865 hypertensive patients, 17 735 (43.4%) met ≥1 screening criterion. Only 736 (4.1%) were screened for PA, with rates varying by indication: 4.7% for resistant hypertension, 8.5% for hypokalemia, 26% for adrenal mass, and 1.6% for obstructive sleep apnea. Of those screened, 213 (28.9%) tested positive. Twenty-six patients (12%) underwent adrenalectomy, 81 (38%) received mineralocorticoid receptor antagonists, and 106 patients (50%) were untreated. Patients undergoing adrenalectomy trended towards fewer major cardiovascular events (2/70, 2.9%) compared with patients managed medically or untreated (25/303, 8.3%; P = .1). At 5 years, patients surgically or medially treated for PA were taking fewer antihypertensive medications, had lower mean systolic blood pressure and greater resolution of hypokalemia compared with untreated patients. CONCLUSIONS: PA remains underdiagnosed and undertreated in high-risk populations. Interventions to improve systematic adherence to guideline-based screening may improve detection, management, and cardiovascular outcomes associated with untreated PA.
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Ngo et al. (2026) conducted a cohort in Hypertension and Primary Aldosteronism (n=40,865). Guideline-based screening and treatment for primary aldosteronism vs. No screening or untreated was evaluated on Screening rates for primary aldosteronism. Only 4.1% of high-risk hypertensive patients were screened for primary aldosteronism, while adrenalectomy trended towards fewer major cardiovascular events compared with medical or no treatment (2.9% vs 8.3%; P=0.1).
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