Endocrine Society experts encouraged more widespread screening for primary aldosteronism – a common hormonal cause of high blood pressure — in a new Clinical Practice Guideline presented during a packed session on the last day of ENDO 2025 in San Francisco and appearing in this month’s Journal of Clinical Endocrinology & Metabolism.
William F. Young, Jr., MD, MSc, recently shared with Endocrine News a few success stories from patients who had been suffering from primary aldosteronism (PA) – a common hormonal cause of high blood pressure. All had opted for the surgical option to treat their PA (more on that later). One patient shared the numbers of their “perfect” blood pressure and expressed excitement over being able to indulge in salty food without affecting blood pressure and went on to say, “At my local doctor appointments, my previous ‘white coat syndrome’ readings are a thing of the past.”
Another patient wrote in an email to Young and his Mayo Clinic team that they no longer felt “very agitated all the time, irritated very easily, very edgy” since their surgery, that their libido had returned after “being almost zero” for two years, and they no longer felt fatigued by walking up the stairs or even just using a hair dryer.
A third patient shared a celebratory picture of themselves at a Bat Mitzvah with their daughters, and thanked Young for bringing back their quality of life.
Young, Tyson Family Endocrinology clinical professor and professor of medicine in the Mayo Clinic College of Medicine at the Mayo Clinic in Rochester, Minn., is co-author of the recently published, “Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline,” which was presented at ENDO 2025 in San Francisco and will appear in the September 2025 issue of The Journal of Clinical Endocrinology & Metabolism. The clinical practice guideline (CPG) updates recommendations from the Society’s 2016 guideline on primary aldosteronism.
A significant minority of people who are diagnosed with hypertension actually have undiagnosed primary aldosteronism. An estimated 5% to 14% of people with high blood pressure seen in primary care and up to 30% seen in referral centers have primary aldosteronism.
Many individuals with hypertension never receive a blood test for primary aldosteronism. When the condition is not diagnosed and treated, it raises the risk of cardiovascular complications, including stroke, coronary artery disease, atrial fibrillation, heart failure, and renal disease, and as seen above, irritability, loss of libido, and extreme fatigue – “lesser” complications than a stroke or heart failure, but still hindrances to a good quality of life.
“People with primary aldosteronism face a higher risk of cardiovascular disease than those with primary hypertension,” says the guideline’s writing group co-chair, Gail K. Adler, MD, PhD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, Mass. “With a low-cost blood test, we could identify more people who have primary aldosteronism and ensure they receive the proper treatment for the condition.”
Significant Departure from Earlier CPGs
The Endocrine Society created its first CPG on PA in 2008, its second in 2016, and now the current one. Anand Vaidya, MD, MMSc, interim chief of the Division of Endocrinology, Diabetes, and Hypertension, and director of the Center for Adrenal Disorders at Brigham and Women’s hospital and co-author of the current CPG, says that it’s approaching the point where a new CPG is needed every 10 years.
“In the last 10 years, there have been major developments on the prevalence, pathogenesis, diagnosis, and management of primary aldosteronism,” Vaidya says. “Therefore, this guideline comes at an important time wherein a comprehensive evidence-based document is needed and desired by the medical community.”
According to co-author Tracy A. Williams, PhD, a scientist in the Department of Medicine IV, Ludwig Maximilian University of Munich, a key difference between this current CPG and previous versions is that the writing group adopted the PICO (Patients, Interventions, Comparator, Outcomes) framework for guideline development. The guideline panel formulated specific PICO questions that address what they considered as the most critical aspects of PA management.
“The Mayo team then performed systematic reviews and meta-analyses for each question,” Williams says. “This is a significant departure from earlier guidelines, representing a more rigorous approach and the development of evidence-based recommendations, where possible.”
The guideline suggests that everyone who is diagnosed with hypertension have their levels of aldosterone, renin, and potassium checked. The guideline authors also suggest patients who are diagnosed with primary aldosteronism should receive treatment specific to the condition. Treatment options include medications and surgery. One of the questions the writing group pose is “Should primary aldosteronism–specific medical therapy vs surgical therapy be used in individuals diagnosed with primary aldosteronism?” and their recommendation is “In individuals with primary aldosteronism (PA), we suggest medical therapy or surgical therapy with the choice of therapy based on lateralization of aldosterone hypersecretion and candidacy for surgery.”
Provider Acceptance
Treatment options again point to the importance of individualized care, but PA remains underdiagnosed and undertreated. Writing group co-chair Michael Stowasser, MBBS, FRAC, PhD, a clinical researcher in the Endocrine Hypertension Research Centre at the University of Queensland, Princess Alexandra Hospital in Brisbane, Australia, says that the main factors for these gaps are: lack of awareness of the high prevalence of PA and the importance of detecting it; the difficulties involved in preparing patients for screening, and especially in withdrawing medications that can interfere with test results; and limited availability of centers who are experienced in the subsequent diagnostic workup (including suppression testing and adrenal venous sampling) and management.
“In the last 10 years, there have been major developments on the prevalence, pathogenesis, diagnosis, and management of primary aldosteronism. Therefore, this guideline comes at an important time wherein a comprehensive evidence-based document is needed and desired by the medical community.” – Anand Vaidya, MD, MMSc, interim chief, Division of Endocrinology, Diabetes, and Hypertension; director, Center for Adrenal Disorders, Brigham and Women’s Hospital, Boston, Mass.
“Unlike the previous CPG,” Stowasser says, “the current guideline tries to address some of these issues by providing a more pragmatic approach to screening (wherein withdrawal of interfering medications can often be avoided), and for subsequent workup and management (for example, giving the provider the option to embark on an empiric trial of targeted medical therapy for PA rather than proceeding to suppression testing and adrenal venous sampling in every case).”
Guideline updates like these should lead to more provider acceptance of PA screening, especially among primary care physicians, who may have limited awareness of PA, difficulties interpreting results in patients on interfering medications, and concerns about the complexity and availability of subtype testing. “In contrast, screening is generally well-accepted by patients, especially at the time of initial hypertension diagnosis,” the authors write. “However, provider hesitancy could limit implementation, particularly in settings with high workloads or limited specialist access.”
The Role of the Endocrinologist
Young wasn’t the only one who shared success stories. Vaidya had the case of a 27-year-old woman with hypertension during her first pregnancy. She was diagnosed with PA, and Vaidya writes in an Interactive Case Presentation in The New England Journal of Medicine that the results of her adrenal venous sampling showed the patient’s right adrenal gland was producing four times as much as the left one. She was advised a right adrenalectomy would be her best – and most cost-effective – option. Her blood pressure returned to normal, even with stopping her antihypertensive medications on postoperative day one.
“When you provide a surgical cure for PA, these are some of the most grateful patients in the field of medicine. Their quality of life is markedly improved, and hypertension is either improved or cured. I have one patient whom we surgically cured nine years ago, and I still get an e-mail from him every year on the anniversary date of his surgery. He thanks our endocrine surgeon and me for ‘giving me my life back.’ This type of outcome is not an exception, it is the rule.” – William F. Young, Jr., MD, MSc, Tyson Family Endocrinology clinical professor; professor of medicine, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minn.
“Ten to 15 years ago, the only cases that were referred to me were those that had extremely severe PA,” Vaidya says. “Now, due to increased local education and awareness in my community and tertiary care medical center, I am referred cases diagnosed much earlier. Thus, I get to see first-hand that there are clinicians changing their practice patterns based on new knowledge.”
Stowasser had a 48-year-old patient in Brisbane with hypertension detected by her primary care physician. She was put on several medications, but they caused rashes, ankle edema, headaches, and nausea. She was referred to Stowasser’s Hypertension Unit where PA was diagnosed, and adrenal venous sampling showed lateralization of aldosterone production to the left adrenal. “By the time she came to surgery she was taking spironolactone, verapamil SR, and prazosin with suboptimal control of hypertension and was experiencing numerous symptoms including headaches, dizziness, nausea, arthralgias, exertional dyspnea, anxiety and ‘brain fog,’” Stowasser says. “Following laparoscopic left adrenalectomy, she became normotensive off all antihypertensive medications and her aldosterone/renin ratio normalized and, at three months post adrenalectomy, reported complete resolution of all symptoms.”
These stories of referrals and subsequent diagnoses speak to the critical roles that endocrinologists play in detecting and treating PA. For Williams, endocrinologists bring specialized expertise in interpreting the complex diagnostic tests in PA management. They also oversee the initiation and titration of mineralocorticoid receptor antagonists, monitor treatment efficacy, and manage any side effects. Endocrinologists also collaborate with interventional radiologists and surgeons when adrenalectomy is indicated, ensuring optimal patient selection. “The expertise of the endocrinologist in multidisciplinary teams, helps to translate Guideline recommendations into effective, patient-centred care, ultimately improving long-term cardiovascular and renal outcomes,” Williams says.
“When you provide a surgical cure for PA, these are some of the most grateful patients in the field of medicine. Their quality of life is markedly improved, and hypertension is either improved or cured,” Young says. “I have one patient whom we surgically cured nine years ago, and I still get an e-mail from him every year on the anniversary date of his surgery. He thanks our endocrine surgeon and me for ‘giving me my life back.’ This type of outcome is not an exception, it is the rule.”
Bagley is the senior editor of Endocrine News. He wrote about the relationship between type 2 diabetes and liver disease, and how endocrinologists can take the lead in treatment.
Loading ...