Endocrine Abstracts

Objectives: Understanding and propagating the knowledge of the burden caused by the massive infradiagnosis of Primary Aldosteronism (PA), partly due to unawareness of its high prevalence and partly to the complexity of its screening in Primary Care and workup in Specialized Care.

Methods: Review of the relevant literature and personal reflections.

Results: PA is the first cause of secondary hypertension and a highly prevalent disease (2–4%). Of the 16,500,000 Spanish hypertensives, at least 1,000,000 have PA. Norwithstanding, it is still widely considered as a rare disease, with <1% diagnosed cases; the rest are managed as essential hypertensives. However, PA:

- Is a potentially curable disease, while essential hypertension rarely is.

- Elicits a burden of cardiovascular complications estimated as fivefold that of essential hypertension with comparable blood pressure.

- It has a more severe impact on mental health and quality of life of the patients than essential hypertension, and higher association with metabolic syndrome and sleep-apnea.

- Blood pressure control in PA is not only more difficult (as it typically drives resistant hypertension), but also the risk of cardiovascular events is not reverted unless the aldosteronism is controlled (with normalization of PRA).

The present guidelines recommend screening for PA in multiple situations that may include 50% of the hypertensive patients. Pharmacologic interferences notoriously hinder the interpretation of the aldosterone/renin ratio. Confirmation test are complex, hazardous and may require hospital admission. Subtyping requires in most cases adrenal venous sampling (AVS) which is highly specialized, invasive, costly and poorly standardized. According to the guidelines we should screen about 8,000,000 patients, perform confirmation tests in >1,000,000 and AVS in about 500,000 in order to proceed to resolutive treatment in most of our patients with PA.

Conclusions: PA is not a rare disease, but it is overwhelmingly infradiagnosed, partly because of ignorance and partly because the screening and diagnostic procedures are exceedingly complex and costly. General implementation of the present guidelines is patently inviable, hence it is unsurprising that <1% of the cases are diagnosed and treated (in Spain as in the rest of the world). Early diagnosis and treatment of PA could potentially reduce very significantly the burden of cardiovascular events (stroke especially) with obvious implications for public health, besides improving the mental health and quality of life of a sizable segment of the population. However, in order to achieve these goals, the PA screening and diagnosis procedures need to be simplified, and their cognizance widened.