SAT-273 - Predictors of Positive Primary Aldosteronism Screening

Background: Primary aldosteronism (PA) is a common cause of secondary hypertension, and an independent risk factor of cardiovascular morbidity and mortality. Despite this, < 3% of individuals at highest risk of PA are ever screened. Recent clinical practice guidelines have expanded the indications for PA screening to all or most patients with hypertension. The high prevalence of hypertension and competing priorities during office visits might overwhelm practicing clinicians. Support tools which can identify clinical features associated with higher likelihood of positive screening could encourage clinicians to test for PA.

Methods: We developed a non-interruptive best-practice alert that identifies patients at high risk for PA, including adults with hypertension and one of the following: taking ≥ 4 current antihypertensive medications; age < 35 years; hypokalemia (defined by potassium supplements or low serum potassium in the past year); or adrenal mass on problem list. The algorithm excluded patients who had both plasma aldosterone and renin measurements within the past 5 years, or were diagnosed with other forms of secondary hypertension. The BPA was set to deploy in patients meeting inclusion and exclusion criteria when evaluated in outpatient setting by clinicians who treat hypertension, including Internists, Family Practitioners, Cardiologists, Nephrologists, and Endocrinologists. We assessed the proportion of patients screened, and we used stepwise logistic regression to identify factors associated with positive PA screening results, as defined by an aldosterone:renin ratio >2.6 (ng/dL)/(pg/mL).

Results: Between Oct 1st 2021-Dec 31st, 2024, the BPA identified 22,626 unique candidates for PA screening based on the 2016 practice guidelines, including 10,353 (46.8%) with treatment-resistant hypertension; 9621 (42.5%) with hypertension and hypokalemia; 2240 (9.9%) with hypertension < 35 years; and 592 (2.6%) with hypertension and an adrenal mass. Of these, 2724 (12%) patients underwent PA screening. Multivariable logistic regression identified independent factors associated with positive PA screening results as: Black race (OR, 95% CI: 2.0 [1.6-2.5] vs White race); older age at screening (OR: 1.03 [1.02-1.04]); not having diabetes mellitus (OR: 1.4 [1.1-1.7]); having treatment-resistant hypertension (OR: 1.7 [1.2-2.4]), hypokalemia (OR: 1.7 [1.2-2.5]), and a higher in office systolic (OR: 1.008 [1.002-1.013]) and diastolic blood pressure (OR: 1.03 [1.03-1.04]). Conversely, gender, weight, cardiovascular comorbidities or kidney function were not associated with screening results.

Conclusions: Factors associated with positive PA screening include Black race, older age, treatment-resistant hypertension, hypokalemia, and not having diabetes. This study design did not allow us to identify early predictors of PA.

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