Definitions for the quality of the evidence (+OOO, ++OO, +++O, and ++++); the strength of the recommendation (1 or 2); and for the difference between a "recommendation" and a "suggestion" are provided at the end of the "Major Recommendations" field.
Case Detection
The Task Force recommends the case detection of primary aldosteronism (PA) in patient groups with relatively high prevalence of PA. (1 | ++OO) These include patients with Joint National Commission (JNC) stage 2 (>160–179/100–109 mm Hg), stage 3 (>180/110 mm Hg), or drug resistant hypertension; hypertension and spontaneous or diuretic-induced hypokalemia; hypertension with adrenal incidentaloma; or hypertension and a family history of early onset hypertension or cerebrovascular accident at a young age (<40 years). The Task Force also recommends case detection for all hypertensive first-degree relatives of patients with PA. (1 | +OOO)
The Task Force recommends use of the plasma aldosterone-renin ratio (ARR) to detect cases of PA in these patient groups. (1 | ++OO)
Case Confirmation
Instead of proceeding directly to subtype classification, the Task Force recommends that patients with a positive aldosterone-renin ratio (ARR) undergo testing, by any of four confirmatory tests, to definitively confirm or exclude the diagnosis. (1 | ++OO)
Subtype Classification
The Task Force recommends that all patients with PA undergo an adrenal computed tomography (CT) scan as the initial study in subtype testing and to exclude large masses that may represent adrenocortical carcinoma. (1 | ++OO)
The Task Force recommends that, when surgical treatment is practicable and desired by the patient, the distinction between unilateral and bilateral adrenal disease be made by adrenal venous sampling (AVS) by an experienced radiologist. (1 | +++O)
In patients with onset of confirmed PA earlier than at 20 years of age and in those who have a family history of PA or of strokes at young age (<40 years), the Task Force suggests genetic testing for glucocorticoid-remediable aldosteronism (GRA). (2 | +OOO)
Treatment
The Task Force recommends that treatment by unilateral laparoscopic adrenalectomy be offered to patients with documented unilateral PA (i.e., aldosterone-producing adenoma [APA] or unilateral adrenal hyperplasia [UAH]). (1 | ++OO) If a patient is unable or unwilling to undergo surgery, the Task Force recommends medical treatment with a mineralocorticoid receptor (MR) antagonist. (1 | ++OO)
In patients with PA due to bilateral adrenal disease, the Task Force recommends medical treatment with an MR antagonist (1 | ++OO); the Task Force suggests spironolactone as the primary agent with eplerenone as an alternative. (2 | +OOO)
In patients with GRA, the Task Force recommends the use of the lowest dose of glucocorticoid that can normalize blood pressure and serum potassium levels rather than first-line treatment with a mineralocorticoid receptor (MR) antagonist. (1 | +OOO)
Definitions:
Strength of Recommendations
1 - Indicates a strong recommendation and is associated with the phrase "The Task Force recommends."
2 - Denotes a weak recommendation and is associated with the phrase "The Task Force suggests."
Quality of the Evidence
+OOO Denotes very low quality evidence
++OO Denotes low quality evidence
+++O Denotes moderate quality evidence
++++ Denotes high quality evidence
