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Primary aldosteronism - the cardiologist's simplistic approach

September 7, 2019 Andrew To
Aldosterone

Aldosterone

Screening for secondary causes of hypertension is important, though often not thought of.

Primary aldosteronism is the most common endocrine cause. The screening test is the aldosterone-renin ratio (ARR). Primary aldosteronism is likely if

  • renin < 8.2mU/L

  • aldosterone >400pmol/L

  • aldosterone-renin ratio > 50

When should we perform ARR

  • Severe hypertension, sustained >150/100 on 3 measurements

  • Resistant hypertension on 3 conventional antiHT incl. diuretics

  • Controlled hypertension on 4 or more antiHT

  • Hypertension with hypokalaemia

  • Adrenal incidentaloma

  • Sleep apnoea

  • First degree relative of primary aldosteronism

  • Family history of early onset hypertension

  • Family history of young strokes

Tips re checking ARR

  • Sodium replete

  • Ambulatory (1-2hr upright or ambulant; mid-morning)

  • Check electrolytes - K

  • No interfering drugs

Differential diagnoses include

  • Bilateral adrenal hyperplasia (idiopathic hyperaldosteronism)

  • Adrenal adenoma

  • Unilateral adrenal hyperplasia

  • Adrenal carcinoma

  • Familial hyperaldosteronism (Type 1,2,3)

Confirmation tests include

  • Saline suppression test

  • Fludrocortisone suppression test

  • Adrenal CT

  • Adrenal vein sampling

Author: Andrew To

In Drug Treatment, Hypertension Tags hypertension, renin, aldosterone
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Copyright @2024 Cardiology Institute; All photos copyright @2024 Andrew To