Determine when to screen for primary aldosteronism in hypertensive patients
STEP 1 — Gather Information
Confirm hypertension diagnosis and collect: serum potassium (spontaneous hypokalemia?), blood pressure readings and medication count (resistant hypertension?), age at hypertension onset, imaging for adrenal tumor, history of stroke before age 40, and sleep apnea evaluation.
STEP 2 — Rule In / Rule Out
Is the patient hypertensive? If no → do not screen for PA; if yes → proceed to assess for high-prevalence features.
STEP 3 — Classify or Stratify
Does the hypertensive patient have any of: spontaneous hypokalemia, resistant hypertension, hypertension onset before 40 years, adrenal tumor on imaging, stroke at a young age, or sleep apnea syndrome? If yes → classify as high suspicion; if no → classify as routine suspicion.
STEP 4 — Decide
High suspicion → screen for PA promptly (e.g., ARR ≥200 with PAC ≥60 pg/mL). Routine suspicion → screen for PA as part of standard hypertension evaluation per guideline recommendation.
Clinical Guardrails / Mimics / Pitfalls
Do not rely solely on hypokalemia to exclude PA; many PA patients have normal potassium. Avoid screening in normotensive individuals unless secondary hypertension is suspected. Do not delay screening in patients with resistant hypertension or adrenal incidentaloma.
Concrete Clinical Example
A 45‑year‑old with hypertension on three medications, BP 158/96 mmHg, and incidental 1.2 cm adrenal nodule on abdominal CT is identified as high suspicion (adrenal tumor + resistant hypertension) and undergoes ARR screening.
Source: Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2021.