Primary Aldosteronism Testing of Veterans With Treatment-Resistant Hypertension Rare

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Testing of veterans with apparent treatment-resistant hypertension for primary aldosteronism was found to be rare.

Testing of veterans with apparent treatment-resistant hypertension for primary aldosteronism was found to be rare and associated with higher rates of evidence-based treatment with mineralocorticoid receptor antagonists (MRAs) and better longitudinal blood pressure control, according to a study published in the Annals of Internal Medicine.

In this retrospective cohort study, the data of 269,010 participants (median age, 65 years; interquartile ratio, 58-72 years; 4% women; 19% Black non-Hispanic) with apparent treatment-resistant hypertension who visited the US Veterans Health Administration (VHA) between 2000 and 2017 were examined. Apparent treatment-resistant hypertension was defined as either 2 blood pressure measurements  ≥140 mm Hg (systolic) or ≥90 mm Hg (diastolic) at least 1 month apart in patients receiving 3 antihypertensive agents (including a diuretic), or hypertension requiring 4 antihypertensive drug classes.

After a median follow-up of 3.3 years, 4277 participants (1.6%) underwent testing for primary aldosteronism. Consultation with a nephrologist or an endocrinologist was associated with a higher likelihood of testing compared with consultation with a primary care physician (hazard ratio [HR], 2.05; 95% CI, 1.66-2.52 and HR, 2.48; 95% CI, 1.69-3.63, respectively). Testing for primary aldosteronism was associated with a 4-fold higher likelihood of MRA therapy initiation (HR, 4.10; 95% CI, 3.68-4.55), as well as with better blood pressure control over time.

“Our data provide evidence of considerable underperformance of guideline-recommended testing for primary aldosteronism in a national cohort of veterans with apparent treatment-resistant hypertension, bolstering similar observations in smaller health systems,” noted the study authors.

Study limitations include a predominantly male cohort, the study’s retrospective design, and the lack of confirmatory testing for primary aldosteronism.

The failure to test for primary aldosteronism in veterans may reflect a lack of familiarity with the condition or a broader tendency for treatment inertia in this population, according to the researchers.

“The consequences of undertesting for primary aldosteronism and underuse of MRAs in patients with apparent treatment-resistant hypertension may be substantial, potentially increasing morbidity and mortality,” the study authors concluded. “We identified several factors associated with undertesting. Given the unique infrastructure of the VHA, our findings suggest an opportunity to introduce innovative practices to meaningfully improve education of providers and increase testing to enhance management in this high-risk patient population.”

Disclosures: Some of the authors reported affiliations with pharmaceutical companies. Please see the original reference for a full list of disclosures.


Cohen JB, Cohen DL, Herman DS, et al. Testing for primary aldosteronism and mineralocorticoid receptor antagonist use among U.S. veterans: A retrospective cohort study [published online December 29, 2020]. Ann Intern Med. doi:10.7326/M20-4873