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Scientific letter
Impact of an endocrine hypertension unit on the diagnosis of primary aldosteronism
Impacto de una consulta de hipertensión endocrina en el diagnóstico del hiperaldosteronismo primario
Jorge Gabriel Ruiz-Sánchez
Corresponding author
gajo_saru@hotmail.com

Corresponding author.
, Diego Meneses
Servicio de Endocrinología y Nutrición, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Arterial hypertension &#40;HT&#41; is the main risk factor for cardiovascular disease and it affects &#8764;50&#37; of the Spanish adult population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Primary aldosteronism &#40;PA&#41; is a chronic&#44; progressive endocrine disorder that is the main cause of HT&#59; it is found in 10&#8211;15&#37; of the hypertensive adult population in general<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and in 30&#37; in cases of severe and&#47;or resistant HT&#46; PA is a major cardiovascular risk factor&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> It increases the risk of death&#44; stroke&#44; coronary heart disease&#44; chronic kidney disease&#44; atrial fibrillation&#44; left ventricular hypertrophy and heart failure more than essential HT and regardless of blood pressure levels&#46; Early detection can therefore save lives and improve the quality of life of those affected&#46;<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Considering the public health impact of PA&#44; all clinicians should be familiar with its management&#46; However&#44; the reality is that identifying PA can be complex&#44; which partly explains the high rate of underdiagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> This seems to be no different among endocrinologists in Spain&#46; Studies from the Spanish PA registry report high rates of hypokalaemia&#44; suggesting that PA is diagnosed in advanced stages&#44; even in very obvious cases&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> A recent Spanish national survey on the treatment of PA by Spanish endocrinologists<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> showed that there is great variability in this area&#44; and that there is a lack of subtyping studies&#44; findings similar to those reported by other authors&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Additionally&#44; it was reported that only 35&#37; of departments had a specific specialist in PA and that&#44; although 67&#37; had an HT clinic&#47;unit at their hospital&#44; these came under other specialist areas&#46; It is likely that the establishment of specific referral centres&#47;units&#47;clinics in HT with endocrinologists subspecialising in PA would improve the management of this condition&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our department boasts a specific endocrine hypertension clinic &#40;C-HT-Endo&#41;&#44; which has been running since January 2022&#46; We report here how this clinic has affected the diagnosis of PA and we discuss our experiences so far&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Operational structure of the clinic</span><p id="par0020" class="elsevierStylePara elsevierViewall">Suspected cases of endocrine hypertension&#44; mainly PA&#44; have been channelled to two endocrinologists since July 2021&#44; and the C-HT-Endo has been running as a specific service two days a week since January 2022&#46; In parallel with the creation of the clinic and once it was up and running&#44; informative sessions were held with the hospital&#39;s Nephrology&#44; Interventional Radiology&#44; Internal Medicine&#44; Cardiology&#44; Urology and Pathology departments to coordinate diagnostic-therapeutic strategies&#46; The patients are referred from the Nephrology HT clinic or from our own department&#46; The reason for referral is suspected endocrine hypertension&#44; which includes PA&#44; pheochromocytoma&#47;paraganglioma&#44; Cushing&#39;s syndrome and acromegaly&#46; In the case of PA&#44; in addition to clinical suspicion&#44; an aldosterone-renin ratio value &#62;20&#8239;ng&#47;dl&#47;ng&#47;mL&#47; with blood aldosterone &#40;Aldo&#41; &#62;8&#8239;ng&#47;dl was agreed on &#40;measured with or without drugs that interfere with the renin-angiotensin-aldosterone system&#41;&#46; For the diagnosis of PA&#44; apart from clinical exceptions&#44; two of the following functional tests are performed using the published protocol and cut-off points&#44;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> in accordance with the latest European consensus&#58;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> captopril challenge test with captopril 25&#8239;mg&#59; oral salt loading test&#59; and intravenous saline loading test&#46; For the study of other causes of endocrine HT&#44; the recommendations of the respective clinical guidelines are followed&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Impact of the C-HT-Endo on the diagnostic approach to PA</span><p id="par0025" class="elsevierStylePara elsevierViewall">From July 2021 to December 2022&#44; 144 patients were seen at the C-HT-Endo&#44; 56 &#40;38&#46;8&#37;&#41; referred from Nephrology and the rest from our department&#46; Of the 144 patients&#44; PA was diagnosed in 46 &#40;31&#46;9&#37;&#41;&#44; and no other cause in the rest&#46; With the clinic&#44; compared to previous years&#44; we have seen a markedly progressive increase in the cases investigated and diagnosed with PA&#44; as well as in the number and the diagnostic yield of adrenal venous sampling procedures performed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Implications of a C-HT-Endo</span><p id="par0030" class="elsevierStylePara elsevierViewall">First of all&#44; although there are clinical guidelines for the management of HT of endocrine origin&#44; apart from PA&#44; it is still a group of unusual diseases&#44; which are highly heterogeneous from a clinical point of view&#46; The logistical constraints of adapting the approach to the particular situation of each centre and getting a clinic of this type effectively up and running are many&#46; Multidisciplinary coordination with the departments involved is therefore imperative to turn what were initially weaknesses into strengths&#46; Secondly&#44; there is no gold standard for diagnostic or therapeutic action in many of these diseases&#44; especially when &#34;unusual&#47;complicated&#34; cases occur&#46; Moreover&#44; as in the case of PA&#44; the performance of many screening&#47;diagnostic tests can vary depending on pre-analytical factors or cut-off points used&#44; or due to the nature of the disease&#46; In PA&#44; the higher the cut-off point of the aldosterone-renin ratio used for screening&#44; the lower its sensitivity&#44; although the higher its specificity&#59; sitting&#47;standing and some drugs induce different values of aldosterone and renin&#59; and production of aldosterone is not always homogeneous&#44; continuous and completely autonomous&#46; Therefore&#44; doctors who run a C-HT-Endo need to have a thorough knowledge of these situations and be aware that interpreting tests and medical decisions often have to be personalised according to the clinical context&#46; This makes it crucial to have clinical meetings&#47;committees in place for the discussion and study of cases&#46; Lastly&#44; in order to effectively manage endocrine hypertension&#44; it is also necessary to have detailed knowledge of essential hypertension&#44; so training in the field of HT beyond endocrine causes is vitally important&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; having a C-HT-Endo has probably led to a more active search for cases of PA by the rest of the physicians&#44; and this would explain the marked increase in the diagnosis of PA in our series&#46; It should also translate into more patients benefiting from better cardiovascular protection after appropriate treatment&#44; which is something we hope to corroborate in the future&#46; We therefore deem the role of an endocrinologist specialising in HT and their participation in HT clinics&#47;units to be vital&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors&#47;contributors</span><p id="par0040" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0045" class="elsevierStylePara elsevierViewall">Conception and design of the manuscript&#58; JGR-S&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0050" class="elsevierStylePara elsevierViewall">Data collection&#58; JGR-S and DM&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0055" class="elsevierStylePara elsevierViewall">Data analysis and interpretation&#58; JGR-S&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4</span><p id="par0060" class="elsevierStylePara elsevierViewall">Drafting&#44; review and approval of the submitted manuscript&#58; JGR-S and DM&#46;</p></li></ul></p></span></span>"
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