Determine whether to use ACTH stimulation during adrenal venous sampling
STEP 1 — Gather Information
Collect patient eligibility for AVS (positive confirmatory test for PA, surgical intent), availability of synthetic ACTH (Cosyntropin), planned AVS protocol (IV bolus vs infusion), timing of blood sampling relative to ACTH, and institutional AVS expertise; then determine if AVS is indicated.
STEP 2 — Rule In / Rule Out
Is adrenal venous sampling (AVS) indicated for subtype diagnosis in primary aldosteronism? If no, do not proceed with ACTH stimulation. If yes, proceed to evaluate ACTH use.
STEP 3 — Classify or Stratify
Classify the goal: If aiming to improve success rate of bilateral selective catheterization during AVS, proceed to recommend ACTH stimulation; if focusing solely on diagnostic accuracy for laterality, note ACTH stimulation’s unclear impact.
STEP 4 — Decide
Recommend administering ACTH stimulation during AVS to increase the selectivity index and achieve successful bilateral selective catheterization.
Clinical Guardrails / Mimics / Pitfalls
ACTH stimulation does not reliably improve diagnostic accuracy for laterality; ensure ACTH‑sampling interval of 15–30 min; avoid use in rare ACTH hypersensitivity; do not substitute ACTH for proper catheter technique or center expertise; consider institutional protocols for ACTH dosing (IV bolus 250 μg or infusion 50–80 μg/h).
Concrete Clinical Example
A 48‑year‑man with PA undergoes AVS at an experienced center; after 250 μg IV ACTH bolus, bilateral selective catheterization achieved (SI ≥ 5), enabling subtype diagnosis and guiding adrenalectomy.
Source: Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2021