Tomography, Vol. 8, Pages 2735-2748: Imaging or Adrenal Vein Sampling Approach in Primary Aldosteronism? A Patient-Based Approach

PA is a frequent cause of secondary hypertension, associated with an increased risk of cardiovascular disease, compared to essential hypertension. Therefore, it is mandatory to promptly recognize the disease and offer to the patient the correct diagnostic–therapeutic process [4,51]. After a correct diagnosis of adrenal aldosterone excess, the treatment of PA requires a skillful combination of imaging and clinical practice, because there are several aspects to consider, as shown in Table 5.For the diagnosis of subtyping in PA, AVS is still the gold standard and should be performed by an expert radiologist in a high-volume center. Since adrenal incidentalomas are common findings in patients with cardiovascular events [53], all efforts should be considered to diagnose PA in these patients. Recently, the discovery of unconventional indices has overcome the impossibility of interpretation of AVS results in which there is incorrect cannulation of one or both adrenal veins. AVS is usually performed with ICM; dexamethasone premedication does not interfere with AVS result and makes AVS a safe procedure in patients with known or suspected allergy.

Our work presented some limitations. The design did not consider a systematic review; in the literature, there are only few evidence-based studies regarding the comparison of different approaches for PA subtyping or treatment. Nonetheless, a practice real-world application of the diagnosis of PA is needed, and we suggest a patient-based approach with some clinical cases.

In conclusion, PA is a spectrum of various diseases and needs a tailored diagnostic–therapeutic process, customized for the individual patient, depending on previous medical history, suitability for surgery, and patient’s preferences. AVS is a safe and informative procedure, and it should be considered in all patients with PA who are good surgical candidates for 10onoliteral adrenalectomy.

Table 5. Key points of the review, presented in the five clinical cases presented, and most relevant studies in the literature.

Table 5. Key points of the review, presented in the five clinical cases presented, and most relevant studies in the literature.

First AuthorCohort DescribedSignificant FindingsAVS is better than imaging to define the subtyping of PAWilliams TA [27]761 patients with unilateral PA (235 with CT management diagnosed from 1994–2016, and 526 with AVS management diagnosed from 1994–2015.Biochemical remission in 80% (188 of 235) cases after a CT-based treatment decision vs. 93% (491 of 526) after an AVS-based treatment decision (p < 0.001).Rossi GP [28]1311 PA patients.Imaging did not detect the culprit adrenal in 28% of the surgically cured unilateral PA patients. The clinical outcome did not differ significantly between the imaging-positive and imaging-negative patients.Surgery is the suggested treatment for monolateral PASatoh M [34]326 PA patients who had received MRA treatment (n = 152) or adrenalectomy (n = 174).Clinical outcomes were not different in after MRAs or adrenalectomy, except for a reduction in the number of antihypertensive drugs after surgery (p < 0.001).Wu V-C [35]858 unilateral PA cases among 1220 PA patients and 1210 essential hypertension controls.Adrenalectomy was associated with lower all-cause mortality of unilateral PA patients, compared to controls (p = 0.017). More beneficial effect of adrenalectomy over MRA treatment on long-term MACE (p < 0.001), atrial fibrillation (p < 0.001), and congestive heart failure (p < 0.001) in unilateral PA patients.Rossi G. P [52]1125 consecutively newly diagnosed hypertensive patients (PA, PH, and IHA).The medical treatment of PA patients was associated with an increase of 82% of relative risk of atrial fibrillation compared with APA (treated with adrenalectomy) and PH (p = 0.025).MRA is able to reduce cardiovascular risk in patients with PACatena C [49]54 consecutive patients who received a diagnosis of PA between 1994 and 2001.Cardiovascular outcome (myocardial infarction, stroke, any type of revascularization procedure, and arrhythmias) was similar to patients with PA treated with adrenalectomy vs. MRAs (p = 0.71).Interpretation of AVS in selected cases (inadequate catheterization, contrast allergy)Younes N [41]7 patients with previous allergic reactions to ICM were prepared for AVS with 3 doses of 7.5 mg dexamethasone.Despite adequate serum cortisol suppression following dexamethasone, the basal and post-ACTH selectivity index confirmed adequate cannulation of both adrenal veins. No allergic reactions were reported.Acharya R [42]Retrospective review of 8 patients with bilateral adrenal masses and AICS (AVS 2008–2016 for cortisol and epinephrine with dexamethasone suppression).AVS was useful in excluding unilateral adenoma as the source of AICS among patients with bilateral adrenal masses and AICS.Ceolotto G [43]136 patients with biochemically confirmed PA, who wished
to pursue the surgical cure.Biochemical cure after adrenalectomy was used to assess the accuracy of LI calculated by using androstenedione, metanephrine and normetanephrine compared to cortisol. The accuracy of LI calculated with the different biomarkers was high for all biomarkers and showed no significant differences (p < 0.0001).Christou F [44]125 PA patients.Assessment of SIs of cortisol, free metanephrine, and the FTMR indices for the AVS procedure. Confirmation that free metanephrine-based SIs are better than those based on cortisol.

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