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. 2021 Mar;174(3):289-297.
doi: 10.7326/M20-4873. Epub 2020 Dec 29.

Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study

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Testing for Primary Aldosteronism and Mineralocorticoid Receptor Antagonist Use Among U.S. Veterans : A Retrospective Cohort Study

Jordana B Cohen et al. Ann Intern Med. 2021 Mar.

Abstract

Background: Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism.

Objective: To evaluate testing rates for primary aldosteronism and evidence-based hypertension management in patients with treatment-resistant hypertension.

Design: Retrospective cohort study.

Setting: U.S. Veterans Health Administration.

Participants: Veterans with apparent treatment-resistant hypertension (n = 269 010) from 2000 to 2017, defined as either 2 blood pressures (BPs) of at least 140 mm Hg (systolic) or 90 mm Hg (diastolic) at least 1 month apart during use of 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive classes.

Measurements: Rates of primary aldosteronism testing (plasma aldosterone-renin) and the association of testing with evidence-based treatment using a mineralocorticoid receptor antagonist (MRA) and with longitudinal systolic BP.

Results: 4277 (1.6%) patients who were tested for primary aldosteronism were identified. An index visit with a nephrologist (hazard ratio [HR], 2.05 [95% CI, 1.66 to 2.52]) or an endocrinologist (HR, 2.48 [CI, 1.69 to 3.63]) was associated with a higher likelihood of testing compared with primary care. Testing was associated with a 4-fold higher likelihood of initiating MRA therapy (HR, 4.10 [CI, 3.68 to 4.55]) and with better BP control over time.

Limitations: Predominantly male cohort, retrospective design, susceptibility of office BPs to misclassification, and lack of confirmatory testing for primary aldosteronism.

Conclusion: In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.

Primary funding source: National Institutes of Health.

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Figures

Figure 1.
Figure 1.
Cohort derivation and primary aldosteronism testing status, initial testing results, MRA use, and adrenalectomy status among participants who met inclusion criteria. MRA = mineralocorticoid receptor antagonist.
Figure 2.
Figure 2.
Proportion of patients with apparent treatment-resistant hypertension tested for primary aldosteronism, by medical center (left) and index year (right). The columns depict the total number of patients with treatment-resistant hypertension (light green) and the total number with treatment-resistant hypertension who were tested for primary aldosteronism (dark green), quantified on the left y-axis. The solid black line depicts the proportion of patients with treatment-resistant hypertension who were tested for primary aldosteronism, quantified on the right y-axis.
Figure 2.
Figure 2.
Proportion of patients with apparent treatment-resistant hypertension tested for primary aldosteronism, by medical center (left) and index year (right). The columns depict the total number of patients with treatment-resistant hypertension (light green) and the total number with treatment-resistant hypertension who were tested for primary aldosteronism (dark green), quantified on the left y-axis. The solid black line depicts the proportion of patients with treatment-resistant hypertension who were tested for primary aldosteronism, quantified on the right y-axis.

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References

    1. GBD 2017 Risk Factor Collaborators. Global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018;392:1923–94. doi:10.1016/S0140-6736(18)32225-6 - DOI - PMC - PubMed
    1. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018;71:e13–e115. doi:10.1161/HYP.0000000000000065 - DOI - PubMed
    1. Carey RM, Sakhuja S, Calhoun DA, et al. Prevalence of apparent treatment-resistant hypertension in the United States. Hypertension. 2019;73:424–31. doi:10.1161/HYPERTENSIONAHA.118.12191 - DOI - PMC - PubMed
    1. van der Sande NGC, de Beus E, Bots ML, et al.; SMART study group. Apparent resistant hypertension and the risk of vascular events and mortality in patients with manifest vascular disease. J Hypertens. 2018;36:143–50. doi:10.1097/HJH.0000000000001494 - DOI - PubMed
    1. Williams B, MacDonald TM, Morant S, et al.; British Hypertension Society’s PATHWAY Studies Group. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY-2): a randomised, double-blind, crossover trial. Lancet. 2015;386:2059–68. doi:10.1016/S0140-6736(15)00257-3 - DOI - PMC - PubMed

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