Performance of the aldosterone-to-renin ratio as a screening test for primary aldosteronism in primary care

Primary aldosteronism (PA) is the most common and potentially curable form of secondary hypertension, affecting 5-10% of primary care patients with hypertension. Primary care physicians have an important role in initiating the screening for PA in patients with hypertension and referring to a specialist service depending on the screening test results. The currently recommended screening test for PA is the plasma aldosterone-to-renin ratio (ARR). Test results are influenced by medications so careful patient preparation is required including adjusting existing antihypertensive medications to avoid diagnostic errors. A range of laboratory method-dependent ARR thresholds are used for the screening of PA around the world. Periodic clinical audits and case reviews by clinicians and the laboratory may help refine the local thresholds. Patients with an abnormally elevated ARR should be referred to a specialist for confirmatory testing while patients with a high pre-test probability but a normal ARR could have a repeat test in view of the within-individual variability. Despite the heterogenous ARR thresholds, measuring the ARR is still more likely to detect PA than not screening at all.