Appraisal of modified tests for the diagnosis and treatment of primary aldosteronism: A single endocrine center experience

Athina Markou; Gregory Kaltsas; Labrini Papanastasiou; Nikolaos Voulgaris; Aggeliki Gouli; Vaios Tsiavos; Christos Gravvanis; Ernestini Tyfoxylou; Sofia Vlachou; Chara Kapsali; Irini Giagourta; Theodora Kounadi; Kyriakos Vamvakidis; George Zografos; George Chrousos; George Piaditis

doi:10.1530/endoabs.99.P418

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Endocrine Abstracts (2024) 99 P418 | DOI: 10.1530/endoabs.99.P418

ECE2024 Poster Presentations Adrenal and Cardiovascular Endocrinology (95 abstracts)

Appraisal of modified tests for the diagnosis and treatment of primary aldosteronism: A single endocrine center experience

Athina Markou ¹ , Gregory Kaltsas ² , Labrini Papanastasiou ¹ , Nikolaos Voulgaris ¹ , Aggeliki Gouli ¹ , Vaios Tsiavos ¹ , Christos Gravvanis ¹ , Ernestini Tyfoxylou ¹ , Sofia Vlachou ² , Chara Kapsali ¹ , Irini Giagourta ¹ , Theodora Kounadi ¹ , Kyriakos Vamvakidis ³ , George Zografos ⁴ , George Chrousos ⁵ & George Piaditis ⁶

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¹General Hospital of Athens ‘G. Gennimatas’, Endocrinology, Athens, Greece; ²Laiko Hospital, 1st Department of Propaedeutic Internal Medicine, Athina, Greece; ³Henry Dunant, Department of Endocrine Surgery, Athina, Greece; ⁴General Hospital of Athens “G. Gennimatas”, Third Department of Surgery, Athens, Greece; ⁵National and Kapodistrian University of Athens, University Research Institute of Maternal and Child Health and Precision Medicine, Athens, Greece; ⁶Henry Dunant, Endocrinology, Athina, Greece

Introduction: Primary aldosteronism (PA), the most common endocrine cause of secondary hypertension, is generally underdiagnosed using current diagnostic tests.

Aim: To present our 14-year experience of prospective studies on the diagnosis, prevalence and treatment of PA.

Patients and methods: We studied 992 hypertensive patients and 278 age-, sex- and body mass index – matched controls (194 normotensive and 104 with essential hypertension), all with normal adrenal imaging. Participants underwent conventional confirmatory tests for PA modified by the addition of dexamethasone to exclude stress-induced aldosterone secretion including the Fludrocortisone Dex Suppression Test (FDST), the Dex Saline Infusion Test (DSIT) and the Dex Captopril Valsartan Test (DCVT). The normotensive controls underwent the FDST and the DSIT. Normal cut-offs of pre-FDST and pre-DSIT basal aldosterone to renin ratio (ARR) and post-FDST and post-DSIT aldosterone levels and ARR were calculated from this group of normotensive controls. Because the DCVT can only be applied to hypertensives, we used hypertensive individuals, in whom PA had been excluded by the FDST, as a control group for calculation of the normal cut-offs of pre-DCVT basal ARR and post-DCVT aldosterone levels and ARR. Hypertensive patients underwent the FDST, the DSIT and the DCVT. Failure to suppress aldosterone was demonstrated if the combination of post-test aldosterone levels and ARR were higher than the corresponding normal cut-offs for each test separately.

Results: Hypertensive patients of all three treatment groups had significantly higher blood pressure (BP) and lower serum potassium levels than their controls. Using the basal ARR, as a screening test, the prevalence of PA was 17.8%, but after applying the modified tests to all patients the prevalence of PA was 33.4%. Targeted treatment with Mineralocorticoid Receptor Antagonists was administered in 252 hypertensive patients with bilateral PA, with 188 (74.6%) obtaining a biochemical response (potassium>3.9 mmol/l, renin> 7.5 mU/l) and a normalized BP (<140/90 mmHg). Forty-eight hypertensive patients with unilateral disease underwent laparoscopic adrenalectomy. Twenty-three of these had concomitant mild autonomous cortisol secretion. Postoperatively, three patients (6.2%) failed to suppress aldosterone, demonstrating a biochemical success rate of 94%.

Conclusion: Our modified methodology and the use of controls for each test separately (normotensives for FDST and DSIT and hypertensives for DCVT) for calculation of normal cut-offs of aldosterone suppression has never been reported before and significantly improves the sensitivity and specificity of the existing tests on the diagnosis of PA, allowing the detection of milder forms some with cortisol co-secretion.