Interpretation of screening tests for primary aldosteronism on and off interfering medications: a systematic review and meta-analysis — ASN Events
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Interpretation of screening tests for primary aldosteronism on and off interfering medications: a systematic review and meta-analysis (#365)

Josephine McCarthy 1 2 3 4 , Ting Wen Pei 3 , Chia An Sheng 3 , Zhong X Lu 5 , Muhammad Akram 6 , Thanh G Phan 3 7 , Jun Yang 3 4 6
  1. Centre for Endocrinology and Reproductive Health, Hudson Institute of Medical Research , Hudson, Clayton, VIC, Australia
  2. Endocrinology & Diabetes, Eastern Health, Box Hill, Victoria
  3. Department of Medicine in the School of Clinical Sciences, Monash Health, Clayton, Victoria, Australia
  4. Department of Endocrinology, Monash Health, Clayton, Victoria, Australia
  5. Monash Health Pathology, Monash Health , Monash Health Pathology, Clayton, Vic, Australia
  6. Centre for Endocrinology and Reproductive Health, Hudson Institute of Medical Research, CERH, Clayton, Victoria, Australia
  7. Department of Neurology, Monash Health, Clayton, Victoria, Australia

 

Aims: Primary aldosteronism (PA), a condition of dysregulated adrenal aldosterone production, is associated with increased cardiovascular risk compared to essential hypertension and has targeted treatment. Recent guidelines recommend screening for PA in all patients with hypertension by measuring an aldosterone-to-renin ratio (ARR). Interpretation of ARR results is challenging in patients taking commonly used antihypertensive medications. The aim of this systematic review and meta-analysis is to demonstrate the impact of interfering antihypertensives on the ARR.

Methods: Two authors independently examined OVID Medline and OVID Embase for studies reporting aldosterone concentration (pmol/L), renin concentration (mU/L) and ARR, on or off interfering medications, in patients with essential hypertension (EH) or PA. Measurements reported in alternative units were converted to standard units.

Results: Of the seventy-eight studies which met inclusion criteria (total 10,144 patients), sixty-eight studies included patients with PA. Only four studies reported ARR both on and off interfering medications in the same patient population (total n 2288), three of these included patients with PA (PA 505, EH 1783). In patients with EH off interfering antihypertensive medications, the pooled median (95% CI) ARR with renin measured by direct renin concentration was 24.3 (95% CI 16.2, 32.4), compared to 13.9 (95% CI 8.7, 19.2) on interfering medications. In patients with PA, the pooled median ARR was 397 (95% CI 31.0, 764.2) when not taking interfering medications, compared to 137.9 (95% CI 81.4, 194.4). In patients with paired measurements before and after medication washout, the ARR ranged between 85 to 125 before washout, and 101 to 357 after washout.

Conclusion: Commonly used antihypertensive medications substantially lower the ARR, potentially masking PA when standard thresholds are applied. Lower medication-adjusted ARR thresholds could improve PA detection without requiring potentially unsafe medication washout. Larger prospective studies are required to establish optimal ARR thresholds according to medication class.