Endocrine Abstracts

Primary aldosteronism (PA), the most frequent form of secondary hypertension, has two main causes: unilateral aldosterone-producing adenoma (APA) and bilateral adrenocortical hyperplasia. APA has the potential for cure of PA by adrenalectomy. In order to identify an APA guidelines advocate adrenal vein sampling (AVS), a technically demanding and expensive procedure of limited availability and with a controversy-raising variety in protocols. CT-scanning is a cheaper and simpler alternative to AVS but its concordance with AVS is poor. The supposed superiority of AVS over CT for selecting patients for adrenalectomy is mostly based on retrospective studies in which management was only guided by AVS and clinical follow-up was often poor, leading to a high risk of bias. We therefore performed a more appropriate, pragmatic diagnostic randomised trial, SPARTACUS (Subtyping PA: a Randomized Trial Comparing AVS and Computed Tomography Scan) in which we used clinical outcomes to determine the clinical value of AVS and CT in 200 patients with PA. The main finding is that clinical outcome after 1 year follow-up, defined as the intensity of antihypertensive treatment, is similar regardless if AVS or CT is used to guide management. Blood pressure, assessed by ambulatory blood pressure measurement, was identical in both groups. The other secondary outcomes, biochemical cure, quality of life were not significantly different. AVS-based management was much more expensive. Intriguingly the concordance between CT and AVS in the AVS arm was only 50%, suggesting that both tests are imperfect to predict biochemical cure after adrenalectomy. Before we can support or discard AVS or CT for subtyping of PA we need more studies with better design. In this debate I will explore what scientific questions must be answered and which hurdles are to be taken in order to improve diagnostic management in PA.