Less Than 1% of Hypertension Cases Screened for Primary Aldosteronism

CHICAGO — One in 12 patients with incident hypertension screened positive for primary aldosteronism, suggesting expanded screening may boost detection, according to a real-world cohort study.

Among 2.5 million adults with incident hypertension, only 18,787 (0.76%) were screened for primary aldosteronism. Of the 9,414 individuals in this group who had available biochemical data, 819 (8.7%) screened positive for primary aldosteronism, reported Diana Grace Varghese, MD, of the University of Maryland in Rockville.

“Only 0.76% of eligible adults with incident hypertension were screened, so expanding screening may meaningfully improve primary aldosteronism detection,” Varghese said at ENDO 2026, the annual meeting of the Endocrine Society. “An 8.7% positive rate in real-world screening is a meaningful yield.”

“We all know primary aldosteronism is a common but underdiagnosed cause of hypertension,” she added.

All individuals with hypertension should be screened for primary aldosteronism, according to Endocrine Society guidelines.

Screening is performed by measuring aldosterone and renin and determining the aldosterone-to-renin ratio. Patients who screen positive are recommended to receive primary aldosterone-specific therapy, which differs from typical hypertension treatment.

Guidelines advise either medical or surgical treatment. Mineralocorticoid receptor antagonists (MRAs) are recommended over epithelial sodium-channel (ENaC) inhibitors in the medical treatment of the condition. Additionally, spironolactone is recommended over other MRAs due to its lower cost and more widespread availability.

“The goal is to increase identification of individuals with primary aldosteronism and, by initiating primary aldosteronism-specific medical or surgical therapy, improve blood pressure control and reduce primary aldosteronism-associated adverse cardiovascular [CV] events,” the guidelines state.

An accurate diagnosis is key, echoed Varghese, as primary aldosteronism is tied to an increased risk for morbidity and mortality as prior data have shown.

A 2023 Swedish study found primary aldosteronism was tied to a 23% higher risk of all-cause mortality, 57% higher risk of CV disease-related death, and 85% higher risk of stroke compared with the general population. Untreated patients were also found to have more than a two-fold higher mortality risk.

Likewise, a 2020 meta-analysis reported a higher 3-year mortality risk for primary aldosterone patients compared with those with essential hypertension.

“Real-world screening yield and the demographic, clinical, and medication-related predictors of a positive screen are not well-characterized,” said Varghese, explaining what led the researchers to the current study.

For their retrospective analysis, they used data from Optum Labs Data Warehouse, a national U.S. claims and electronic health record database. They looked at data collected from 2011 to 2023. The cohort’s mean age was 52, 56% were women, and 58% were white.

A positive primary aldosterone screen was defined as a suppressed renin of ≤1 ng/mL/h or <8 pg/mL, or a direct renin concentration of <8 mU/L plus aldosterone ≥10 ng/dL.

Several predictors of a positive screen were also identified:

• Age ≥75 vs <25: OR 4.03
• Age 25-34 vs <25: OR 2.46
• Asian vs white race: OR 1.91
• Black vs white race: OR 1.80
• Hypokalemia: OR 1.50
• Beta-blocker use: OR 1.45
• Female sex: OR 1.37
• Hispanic/Latino ethnicity: OR 1.36
• Calcium channel blocker use: OR 1.30
• Presence of diabetes: OR 1.26

Conversely, using RAAS inhibitors (OR 0.78) and having heart failure (OR 0.54) were tied to lower odds of a positive screen.

Varghese acknowledged study limitations, which included its observational design, missing lab data for nearly half of the screened population, and potential selection bias. Future studies are needed to determine whether broader or risk-based screening improves primary aldosteronism outcomes, she concluded.