Objective: Research in recent years has demonstrated that the conventional binary approach to primary aldosteronism (PA) work-up is inadequate due to the continuous nature of aldosterone secretion autonomy. PA is vastly underdiagnosed worldwide. Therefore, a sensitivity-oriented approach to PA has been implemented in our tertiary endocrine center. We aimed at comparing PA management outcomes before and after introduction of a systematic PA diagnostic approach. Design and method: Single-center, retrospective, before-and-after study, comparing two 12-month periods: before and after implementation of a systematic diagnostic approach toward PA. Outcomes included the number of screenings, confirmatory tests, adrenal vein sampling procedures, and therapy results. Results: In the 12 months after implementing a systematic diagnostic approach (March 2024 – February 2025) compared with the preceding 12 months (November 2022 – October 2023), PA screening in normokalemic patients with indications for work-up increased from 61% to 82% (total n=264 and 402, respectively), p<0.001. Confirmatory testing more than doubled (37 out of 275 screened patients in the first period versus 102 out of 432 in the second period). Among all patients with an indication for PA work-up, confirmed PA cases prevalence increased from 2.9% (13/447) to 10.9% (57/522) (p<0.001). Suppression testing positivity increased from 29.7% to 51% (p=0.03). Cases with autonomous aldosterone secretion not meeting formal PA criteria were also treated with mineralocorticoid receptor antagonists (MRA), resulting in a more than three-fold increase in the total rate of newly-prescribed MRAs (p<0.001) among patients who underwent work-up (11/275 versus 57/432). Clinical and biochemical outcomes were favorable in both surgically and medically-treated patients. In the second period, adverse effects occurred in two patients; PA was ruled out in three others on repeat testing.Conclusions: The 2025 Endocrine Society guideline fundamentally reframed the PA diagnosis into a probabilistic model. We provide real-world data of how a systematic diagnostic approach can be implemented into clinical practice. Sensitivity-oriented PA management improved PA testing rates and led to more frequent implementation of PA-targeted pharmacotherapy that was favorable for our patients.
Kmieć et al. (2026) studied this question.