Topic Discussion: Primary aldosteronism: You can’t find it if you don’t look for it

Here is a guest post straight from the author of a recent study in Annals of Internal Medicine. 

Visual abstract from Annals of IM website.

As a group of clinical hypertension specialists and researchers, my co-authors and I performed this study out of concern of under-recognition of primary aldosteronism as a common cause of secondary hypertension. Treatment-resistant hypertension occurs in about 20% of adults with hypertension and primary aldosteronism is a common cause of treatment-resistant hypertension. Identification and appropriate management of primary aldosteronism can reduce the risk of development and progression of heart disease and chronic kidney disease. Although guidelines recommend testing for primary aldosteronism in all patients with treatment-resistant hypertension, prior evidence in small, local health systems suggested extremely low rates of screening with plasma renin and aldosterone levels.

In a nationally representative cohort of over 250,000 Veterans with treatment resistant hypertension we found that rates of guideline-based testing for primary aldosteronism from 2000 to 2017 occurred in less than 2% of patients in whom it’s recommended. We identified several patient-, provider-, and center-level factors associated with better screening practices (such as being seen by an endocrinologist or nephrologist, or being cared for at a non-rural medical center). We were surprised to observe that patient adherence, which was identified by medication fills from the pharmacy, was not associated with screening practices. We found that patients who were screened were 4-times more likely to be managed with evidence-based antihypertensive therapy with mineralocorticoid antagonists (regardless of the screening results) compared with patients who were not screened. We also found that patients who were screened had much better blood pressure control over time, also regardless of the results of the screening.

Overall, we observed widespread and concerning missed opportunities for primary aldosteronism screening and for appropriate treatment of patients with treatment-resistant hypertension. The fact that screening practices are strongly associated with evidence-based treatment of apparent treatment-resistant hypertension and blood pressure control over time suggests that good provider behaviors beget other good behaviors, that there are major gaps in provider knowledge of the importance of screening these patients, and that there are likely barriers to implementing appropriate management for these patients. 

These findings suggest a need to improve education of providers and to leverage innovative tools to increase screening and appropriate management of patients with treatment resistant hypertension.

Tweetorial: https://twitter.com/jordy_bc/status/1343678945393315840?s=20

 

Post by:  Jordana Cohen, MD, MSCE

Assistant Professor of Medicine and Epidemiology

Perelman School of Medicine, University of Pennsylvania