Screening for Primary Aldosteronism in Essential Hypertension: Diagnostic Accuracy of the Ratio of Plasma Aldosterone Concentration to Plasma Renin Activity
Abstract
Background: The ratio of plasma aldosterone concentration to plasma renin activity (PRA) is considered the screening test of choice for primary aldosteronism. Uncertainty exists, however, regarding its diagnostic accuracy and the effects of antihypertensive drugs and dietary sodium balance on test characteristics. Methods: We measured PRA and aldosterone in 118 white adults [71 men and 47 women; mean (SD) age, 51 (7) years] with previously diagnosed essential hypertension. Measurements were made while individuals were on antihypertensive drug therapy, after a 2-week drug-free period, after 4 days of dietary sodium loading, and after acute furosemide diuresis. We measured 24-h urine aldosterone excretion and PRA on the 4th day of dietary sodium loading to establish the diagnosis of primary aldosteronism. ROC curves were constructed for ratios measured under each clinical condition, and likelihood ratios were determined for individuals on or off antihypertensive drug therapy. Results: Fifteen patients [13%; 95% confidence interval (CI), 7–20%] met the reference standard for primary aldosteronism. The mean (SD) areas under the ROC curves did not differ significantly across conditions of measurement [range, 0.80 (0.10) to 0.85 (0.04); P = 0.72]. When measured on and off antihypertensive drug therapy, the 95% CIs for the optimum cutpoint for the ratio overlapped. Point estimates of sensitivity on and off therapy were 73% (95% CI, 50–96%) and 87% (70–100%), respectively, and specificities were 74% (65–83%) and 75% (66–84%). Under either condition, increased ratios were associated with 2.4- to 13-fold increases of posttest odds above pretest odds. Conclusions: The aldosterone:PRA ratio provides only fair diagnostic accuracy in screening for primary aldosteronism, but concomitant antihypertensive drug therapy or acute variation in dietary sodium balance does not adversely affect test accuracy. Reporting of likelihood ratios associated with ranges of values of the aldosterone:PRA ratio, rather than use of a single “optimum” cutpoint, may enhance the usefulness of the test.
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The aldosterone-to-renin ratio is an effective screening test because it has a high negative predictive value for screening of primary aldosteronism.
“The ratio is an effective screening test because it has a high negative predictive value for screening of primary aldosteronism.344,345”
From Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association (2018) · cites this paper as [345]
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- Authors
- Schwartz, G. L., & Turner, S. T.
- Affiliations
- Mayo Clinic (US)
- Corresponding author
- Schwartz, Gary L
- Venue
- Clinical Chemistry
- Publisher
- Oxford University Press (OUP)
- Published
- 2005-02-01
- Volume
- 51
- Issue
- 2
- Pages
- 386-394
- ISSN
- 0009-9147 (ISSN-L)
- 1530-8561
- OpenAlex
- W2046753220
- Cited by
- 221
- References
- 31
- Citations by year
- 2026: 3 · 2025: 2 · 2024: 5 · 2023: 6 · 2022: 6 · 2021: 4 · 2020: 13 · 2019: 4 · 2018: 6 · 2017: 12 · 2016: 15 · 2015: 11 · 2014: 11 · 2013: 14 · 2012: 19
- FWCI
- 8.90
- Type
- journal article
- Language
- en
- Open access
- closed
- Licence
- academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model (vor)
- Locations
- Clinical Chemistry (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Heart, Lung, and Blood Institute (R01HL53330, R01HL053330)
- National Center for Research Resources (M01-RR00 585, M01RR000585)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hormonal Regulation and Hypertension
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Renin-Angiotensin System Studies
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Adrenal Hormones and Disorders
- Keywords
- primary aldosteronism, essential hypertension, screening, diagnostic accuracy, antihypertensive drugs, likelihood ratios, cut-off values
- MeSH terms
- Adult, Aldosterone, Antihypertensive Agents, Female, Humans, Hyperaldosteronism, Hypertension, Male, Middle Aged, Plasma, Reference Standards, Renin, Sodium, Dietary, Prevalence
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