Summary of Screening of Primary Aldosteronism and Management of Hypertension as per American College of Cardiology (ACC)/American Heart Association (AHA)

Since the release of the 2017 American College of Cardiology (ACC)/American Heart Association (AHA) Blood Pressure (BP) Guidelines, several key findings have emerged regarding the prevention, detection, and management of hypertension.

The guidelines also provide comprehensive recommendations for identifying potential secondary hypertension through historical, physical, and laboratory assessments, particularly in younger patients or those with treatment-resistant hypertension. Recognizing a secondary cause can lead to a cure for hypertension or better blood pressure management if a complete cure isn't possible. Recent updates in the treatment of primary aldosteronism have emerged.

New research indicates that primary aldosteronism exists within a spectrum of conditions characterized by excess aldosterone. Studies suggest that aldosterone excess may influence primary hypertension and related conditions, even when the plasma aldosterone/renin ratio (ARR) screening test shows negative results. An analysis involving various patient groups revealed that primary aldosteronism can be found in 11.3% of normotensive individuals and up to 22% of those with hypertension, with higher prevalence correlating to more severe hypertension. The ARR was found to have low sensitivity and predictive value, especially when renin levels are low.

Furthermore, a study highlighted that only 1.6% of patients with resistant hypertension in the Veterans Administration system were screened using ARR, indicating a significant number of primary aldosteronism cases may be overlooked. These findings imply that aldosterone excess could also contribute to primary hypertension and might be an unrecognized factor in resistant hypertension. For patients with low renin levels, particularly those with uncontrolled or resistant hypertension, it is crucial to assess urinary aldosterone excretion after salt loading, rather than relying solely on the ARR. 

Summary of Key Findings (January 2018 - March 2021) and Significant for Hypertension Management

• Blood pressure (BP) control rates improved steadily until 2013-2014, after which they began to decline. Following the 2017 ACC/AHA BP guidelines could help reverse this concerning trend.
• Out-of-office BP monitoring methods, such as ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), are recommended to identify white coat hypertension (WCH) and masked hypertension (MH), with ABPM being more effective for detecting MH.
• HBPM is the most practical approach for documenting BP to adjust medications and achieve target BP levels.
• Autonomous aldosterone production may contribute to the development of Stages 1 and 2 hypertension and resistant hypertension. Screening for primary aldosteronism is advised for adults with difficult-to-control hypertension. If the aldosterone-to-renin ratio is low and plasma renin is also low, a 24-hour urine aldosterone test during a high-sodium diet may be warranted.
• Young adults with hypertension experience cardiovascular disease (CVD) events earlier than those with normal BP, suggesting that delaying treatment may not be appropriate. Initial management should involve lifestyle changes for 6-12 months, followed by antihypertensive medications if BP remains elevated.
• Lifestyle modifications are fundamental to managing hypertension. Each nonpharmacological intervention effectively reduces BP, and using multiple interventions concurrently enhances their effectiveness. These modifications also improve the impact of pharmacological treatments.
• Intensive BP control does not lead to increased hospitalizations or a higher risk of orthostatic hypotension. Asymptomatic orthostatic hypotension in hypertensive patients is not linked to higher rates of CVD events, falls, or acute kidney failure, and should not prompt a reduction in treatment.
• For older adults with hypertension, aggressive BP management may help prevent or slow cognitive decline.
• Resistant hypertension is defined as having a BP of ≥130/80 mm Hg in adults taking three or more antihypertensive medications from different classes at maximum tolerated doses, or BP <130/80 mm Hg requiring four or more medications after ruling out pseudo-resistance factors.
• Effective BP cotrol in hypertensive patients is best achieved through comprehensive implementation strategies, including team-based care. • Home BP self-monitoring and telemonitoring are beneficial for facilitating medication adjustments, leading to successful BP management.ntrol in hypertensive patients is best achieved through comprehensive implementation strategies, including team-based care.
• Home BP self-monitoring and telemonitoring are beneficial for facilitating medication adjustments, leading to successful BP management.

Source: Carey RM, Wright JT Jr, Taler SJ, Whelton PK. Guideline-Driven Management of Hypertension: An Evidence-Based Update. Circ Res. 2021 Apr 2;128(7):827-846. doi: 10.1161/CIRCRESAHA.121.318083. Epub 2021 Apr 1. PMID: 33793326; PMCID: PMC8034801.