VI. Endocrine Hypertension

A Hyperaldosteronism: Screening and Diagnosis

1) Screening for hyperaldosteronism should be considered for at least the following patients (Grade D):

  1. hypertensive patients with spontaneous hypokalemia (potassium level lower than 3.5 mmol/L);
  2. hypertensive patients with marked diuretic-induced hypokalemia (potassium level lower than 3.0 mmol/L);
  3. patients with hypertension refractory to treatment with three or more drugs; and
  4. hypertensive patients found to have an incidental adrenal adenoma.

2) Screening for hyperaldosteronism should include assessment of plasma aldosterone and plasma renin activity (Table 6).

3) For patients with suspected hyperaldosteronism (on the basis of the screening test, Table 6 (iii), a diagnosis of primary aldosteronism should be established by demonstrating inappropriate autonomous hypersecretion of aldosterone using at least one of the maneuvers listed in Table 6 (iv). When the diagnosis is established, the abnormality should be localized using any of the tests described in Table 6 (v).

B Pheochromocytoma Screening and Diagnosis

1) If pheochromocytoma is strongly suspected, the patient should be referred to a specialized hypertension center, particularly if biochemistry screening tests Table 7 have already been found to be positive (Grade D).

2) The following patients should be considered for screening for pheochromocytoma (Grade D):

  1. patients with paroxysmal and/or severe (BP 180/110 mm Hg or higher) sustained hypertension refractory to usual antihypertensive therapy;
  2. patients with hypertension and multiple symptoms suggestive of catecholamine excess (e.g., headaches, palpitations, sweating, panic attacks and pallor);
  3. patients with hypertension triggered by beta-blockers, monoamine oxidase inhibitors, micturition, or changes in abdominal pressure; and
  4. patients with incidentally discovered adrenal mass, patients with hypertension and multiple endocrine neoplasia (MEN) 2A or 2B, von Recklinghausen’s disease (neurofibromatosis), or von Hippel-Lindau disease.

3) For patients with positive biochemical screening tests, localization of pheochromocytomas should employ magnetic resonance imaging (preferable), computed tomography (if MRI is unavailable), and/or iodine-131 metaiodobenzylguan (MIBG) scintigraphy (Grade C for each modality).

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