Screening for Primary Hyperaldosteronism

High-Risk Populations Requiring Screening

The American College of Cardiology and European Society of Cardiology recommend screening all hypertensive patients who have resistant hypertension, hypokalemia, an incidentally discovered adrenal mass, family history of early-onset hypertension, or stroke before age 40 years 1, 2
Resistant hypertension, defined as blood pressure >140/90 mmHg despite three antihypertensive medications including a diuretic, or requiring four or more drug classes, is a mandatory screening indication, with primary aldosteronism prevalence reaching 11-20% in this population 1, 2, 3
Hypokalemia, either spontaneous or diuretic-induced, is another indication for screening, although it is absent in the majority (>50%) of primary aldosteronism cases 1, 2
An incidentally discovered adrenal mass on CT or MRI performed for other reasons is also a screening indication 1, 2
A family history of early-onset hypertension or stroke at young age (<40 years) suggests possible glucocorticoid-remediable aldosteronism (familial hyperaldosteronism type-1) and is a screening indication 1, 2

The plasma aldosterone-to-renin ratio (ARR) is the screening test of choice, with a most commonly used cutoff of ARR >30 (when aldosterone in ng/dL and renin activity in ng/mL/h) 1, 2, 6
The 2024 ESC Guidelines acknowledge two pragmatic strategies for ARR testing: testing without medication changes (preferred for efficiency) or optimizing medications before testing (for "clean" results) 4, 5

The American College of Cardiology recommends referring all patients with positive screening tests to a hypertension specialist or endocrinologist for confirmatory testing and treatment 1, 2, 6
Confirmatory testing (saline suppression, fludrocortisone suppression) is required after positive screening, and subtype determination via adrenal vein sampling is crucial to distinguish unilateral (surgical) from bilateral (medical) disease 7

Primary aldosteronism carries increased cardiovascular disease risk that may be partly independent of blood pressure elevation, and the deleterious effects of aldosterone excess are often reversible with appropriate treatment (surgery or mineralocorticoid receptor antagonists) 1, 2, 3, 4, 5