Is Primary Aldosteronism a Benign Disorder? Old Evidence Reconfirmed

Extract

Mansoor et al report eight subjects with presumed primary aldosteronism presenting as “hypertensive emergencies.”¹ This retelling of an old observation is worthy of recognition, as many individuals erroneously believe primary aldosteronism to be a mild and relatively innocuous form of hypertension. In the past 50 years the diagnosis of primary aldosteronism has moved from a 2-week, metabolic ward exercise offered by a small number of institutions with the requisite techniques for measuring aldosterone and renin under very exacting clinical conditions of sodium loading and sodium and volume depletion to a simpler outpatient screening test (plasma aldosterone [PA]–to-renin [PRA] ratios) followed by more specific diagnostic and localizing tests.² Several caveats are appropriate regarding the use of this ratio. False positive results (ie, ratios greater than 20 or 30) can be obtained frequently by the use of a denominator (PRA) that is below the typical limit of sensitivity (ie, 0.1 to 0.7). Setting the lowest value for PRA at 0.7 then requires that PA be ≥14. The patient designated as case 5 in the Mansoor et al report had PA/PRA of 150 and 250 because of the use of 0.1 for PRA.¹