Determine when AVS can be bypassed for suspected bilateral PA
STEP 1 — Gather Information
Collect serum potassium to confirm normokalemia, perform adrenal CT to assess for tumors, and record sex, age, body mass index (BMI), plasma aldosterone concentration (PAC), aldosterone-to-renin ratio (ARR), and any confirmatory test results.
STEP 2 — Rule In / Rule Out
If serum potassium is normal (normokalemia) and adrenal CT shows no adrenal tumors, proceed to classify as likely bilateral PA; otherwise, consider AVS for subtype differentiation.
STEP 3 — Classify or Stratify
Assess likelihood of bilateral PA using additional clinical features: older age, female sex, higher BMI, lower PAC, lower ARR, and confirmatory test results favoring bilateral disease; classify as suspected bilateral PA when these features support bilateral etiology.
STEP 4 — Decide
Recommend initiating medical therapy with a mineralocorticoid receptor antagonist (MRA) and bypass adrenal venous sampling (AVS) after obtaining sufficient informed consent.
Clinical Guardrails / Mimics / Pitfalls
Do not bypass AVS in patients with hypokalemia, adrenal tumors on CT, or unilateral PA predictors (e.g., young age, unilateral tumor, high PAC); do not omit informed consent; do not rely solely on normokalemia and normal CT without considering other clinical features; do not proceed to surgery without AVS when bilateral PA is uncertain.
Concrete Clinical Example
A 58‑year‑old woman with hypertension, serum potassium 4.2 mmol/L, adrenal CT showing no masses, PAC 15 pg/mL, ARR 250, and a positive saline infusion test is classified as likely bilateral PA; she starts spironolactone 50 mg daily and AVS is omitted after discussing risks and benefits.
Source: Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2021