Implementation of a formal sleep center–based screening protocol for primary aldosteronism in patients with obstructive sleep apnea

Published:October 02, 2022DOI:



      There is a bidirectional association between primary aldosteronism and obstructive sleep apnea, with evidence suggesting that the treatment of primary aldosteronism can reduce obstructive sleep apnea severity. Current guidelines recommend screening for primary aldosteronism in patients with comorbid hypertension and obstructive sleep apnea, identifying potential candidates for treatment. However, emerging data suggest current screening practices are unsatisfactory. Moreover, data regarding the true incidence of primary aldosteronism among this population are limited. This study aimed to assess the primary aldosteronism screening rate among patients with obstructive sleep apnea and hypertension at our institution and estimate the prevalence of primary aldosteronism among this population.


      Sleep studies conducted at our institution between January and September 2021 were retrospectively reviewed. Adult patients with a sleep study diagnostic of obstructive sleep apnea (respiratory disturbance index ≥5) and a diagnosis of hypertension were included. Patient medical records were reviewed and laboratory data of those with biochemical screening for primary aldosteronism were assessed by an experienced endocrinologist. Screening rates were compared before and after initiation of a screening protocol in accordance with the 2016 Endocrine Society guidelines.


      A total of 1,005 patients undergoing sleep studies were reviewed; 354 patients had comorbid obstructive sleep apnea and hypertension. Patients were predominantly male (67%), with a mean age of 58 years (standard deviation = 12.9) and mean body mass index of 34 (standard deviation = 8.1). The screening rate for primary aldosteronism among included patients was 19% (n = 67). The screening rate was significantly higher after initiation of a dedicated primary aldosteronism screening protocol (23% vs 12% prior; P = .01). Fourteen screens (21%) were positive for primary aldosteronism, whereas 45 (67%) were negative and 8 (12%) were indeterminate. Four had prior abdominal cross-sectional imaging, with 3 revealing an adrenal adenoma. Compared with patients without primary aldosteronism, patients with positive primary aldosteronism screens were more likely to have a history of hypokalemia (36% vs 4.4%; P = .002). The frequency of hyperlipidemia, diabetes mellitus, and left ventricular hypertrophy did not differ between patients with positive versus negative screens.


      Current screening practices for primary aldosteronism among patients with comorbid obstructive sleep apnea and hypertension are suboptimal. Patients evaluated at sleep centers may represent an optimal population for screening, as the prevalence of primary aldosteronism among this cohort appears high.
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        • Dick S.M.
        • Queiroz M.
        • Bernardi B.L.
        • Dall'Agnol A.
        • Brondani L.A.
        • Silveiro S.P.
        Update in diagnosis and management of primary aldosteronism.
        Clin Chem Lab Med. 2018; 56: 360-372
        • Fagugli R.M.
        • Taglioni C.
        Changes in the perceived epidemiology of primary hyperaldosteronism.
        Int J Hypertens. 2011; 2011162804
        • Baguet J.P.
        • Steichen O.
        • Mounier-Vehier C.
        • Gosse P.
        SFE/SFHTA/AFCE consensus on primary aldosteronism, part 1: epidemiology of PA, who should be screened for sporadic PA?.
        Ann Endocrinol (Paris). 2016; 77: 187-191
        • Savard S.
        • Amar L.
        • Plouin P.F.
        • Steichen O.
        Cardiovascular complications associated with primary aldosteronism: a controlled cross-sectional study.
        Hypertension. 2013; 62: 331-336
        • Prejbisz A.
        • Kolodziejczyk-Kruk S.
        • Lenders J.W.M.
        • Januszewicz A.
        Primary aldosteronism and obstructive sleep apnea: is this a bidirectional relationship?.
        Horm Metab Res. 2017; 49: 969-976
        • Dudenbostel T.
        • Calhoun D.A.
        Resistant hypertension, obstructive sleep apnoea and aldosterone.
        J Hum Hypertens. 2012; 26: 281-287
        • Jin Z.N.
        • Wei Y.X.
        Meta-analysis of effects of obstructive sleep apnea on the renin-angiotensin-aldosterone system.
        J Geriatr Cardiol. 2016; 13: 333-343
        • Florczak E.
        • Prejbisz A.
        • Szwench-Pietrasz E.
        • et al.
        Clinical characteristics of patients with resistant hypertension: the RESIST-POL study.
        J Hum Hypertens. 2013; 27: 678-685
        • Gonzaga C.C.
        • Gaddam K.K.
        • Ahmed M.I.
        • et al.
        Severity of obstructive sleep apnea is related to aldosterone status in subjects with resistant hypertension.
        J Clin Sleep Med. 2010; 6: 363-368
        • Buffolo F.
        • Li Q.
        • Monticone S.
        • et al.
        Primary aldosteronism and obstructive sleep apnea: a cross-sectional multi-ethnic study.
        Hypertension. 2019; 74: 1532-1540
        • Dobrowolski P.
        • Kolodziejczyk-Kruk S.
        • et al.
        Primary aldosteronism is highly prevalent in patients with hypertension and moderate to severe obstructive sleep apnea.
        J Clin Sleep Med. 2021; 17: 629-637
        • Di Murro A.
        • Petramala L.
        • Cotesta D.
        • et al.
        Renin-angiotensin-aldosterone system in patients with sleep apnoea: prevalence of primary aldosteronism.
        J Renin Angiotensin Aldosterone Syst. 2010; 11: 165-172
        • Wolley M.J.
        • Pimenta E.
        • Calhoun D.
        • Gordon R.D.
        • Cowley D.
        • Stowasser M.
        Treatment of primary aldosteronism is associated with a reduction in the severity of obstructive sleep apnoea.
        J Hum Hypertens. 2017; 31: 561-567
        • Sawka A.M.
        • Young W.F.
        • Thompson G.B.
        • et al.
        Primary aldosteronism: factors associated with normalization of blood pressure after surgery.
        Ann Intern Med. 2001; 135: 258-261
        • Rossi G.P.
        • Cesari M.
        • Cuspidi C.
        • et al.
        Long-term control of arterial hypertension and regression of left ventricular hypertrophy with treatment of primary aldosteronism.
        Hypertension. 2013; 62: 62-69
        • Fourkiotis V.
        • Vonend O.
        • Diederich S.
        • et al.
        Effectiveness of eplerenone or spironolactone treatment in preserving renal function in primary aldosteronism.
        Eur J Endocrinol. 2013; 168: 75-81
        • Funder J.W.
        • Carey R.M.
        • Mantero F.
        • et al.
        The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical practice guideline.
        J Clin Endocrinol Metab. 2016; 101: 1889-1916
        • Conroy P.C.
        • Hernandez S.
        • Graves C.E.
        • et al.
        Screening for primary aldosteronism is underutilized in patients with obstructive sleep apnea.
        Am J Med. 2022; 135: 60-66
        • Epstein L.J.
        • Kristo D.
        • Strollo Jr., P.J.
        • et al.
        Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults.
        J Clin Sleep Med. 2009; 5: 263-276
        • Papadopoulou-Marketou N.
        • Vaidya A.
        • Dluhy R.
        • Chrousos G.P.
        Feingold K.R. Anawalt B. Boyce A. Hyperaldosteronism. Endotext. South Dartmouth, MA2000
        • Vaidya A.
        • Carey R.M.
        Evolution of the primary aldosteronism syndrome: updating the approach.
        J Clin Endocrinol Metab. 2020; 105: 3771-3783
        • Kaplan N.M.
        Hypokalemia in the hypertensive patient, with observations on the incidence of primary aldosteronism.
        Ann Intern Med. 1967; 66: 1079-1090
        • Rossi G.P.
        • Bernini G.
        • Caliumi C.
        • et al.
        A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients.
        J Am Coll Cardiol. 2006; 48: 2293-2300
        • Schwartz G.L.
        • Turner S.T.
        Screening for primary aldosteronism in essential hypertension: diagnostic accuracy of the ratio of plasma aldosterone concentration to plasma renin activity.
        Clin Chem. 2005; 51: 386-394
        • Catena C.
        • Colussi G.
        • Nadalini E.
        • et al.
        Cardiovascular outcomes in patients with primary aldosteronism after treatment.
        Arch Intern Med. 2008; 168: 80-85
        • McCarthy J.
        • Yang J.
        • Clissold B.
        • Young M.J.
        • Fuller P.J.
        • Phan T.
        Hypertension management in stroke prevention: time to consider primary aldosteronism.
        Stroke. 2021; 52: e626-e634
        • Ahmed A.H.
        • Gordon R.D.
        • Sukor N.
        • Pimenta E.
        • Stowasser M.
        Quality of life in patients with bilateral primary aldosteronism before and during treatment with spironolactone and/or amiloride, including a comparison with our previously published results in those with unilateral disease treated surgically.
        J Clin Endocrinol Metab. 2011; 96: 2904-2911
        • Buffolo F.
        • Monticone S.
        • Burrello J.
        • et al.
        Is primary aldosteronism still largely unrecognized?.
        Horm Metab Res. 2017; 49: 908-914
        • Grigoryan S.
        • Konzen S.M.
        • Turcu A.F.
        Rates of primary aldosteronism screening among high-risk populations.
        J Endocr Soc. 2021; 5: A297-A298
        • Jaffe G.
        • Gray Z.
        • Krishnan G.
        • et al.
        Screening rates for primary aldosteronism in resistant hypertension: a cohort study.
        Hypertension. 2020; 75: 650-659
        • Ruhle B.C.
        • White M.G.
        • Alsafran S.
        • Kaplan E.L.
        • Angelos P.
        • Grogan R.H.
        Keeping primary aldosteronism in mind: deficiencies in screening at-risk hypertensives.
        Surgery. 2019; 165: 221-227
        • Monticone S.
        • Burrello J.
        • Tizzani D.
        • et al.
        Prevalence and clinical manifestations of primary aldosteronism encountered in primary care practice.
        J Am Coll Cardiol. 2017; 69: 1811-1820
        • Chee M.R.
        • Hoo J.
        • Libianto R.
        • et al.
        Prospective screening for primary aldosteronism in patients with suspected obstructive sleep apnea.
        Hypertension. 2021; 77: 2094-2103
        • Calhoun D.A.
        • Nishizaka M.K.
        • Zaman M.A.
        • Harding S.M.
        Aldosterone excretion among subjects with resistant hypertension and symptoms of sleep apnea.
        Chest. 2004; 125: 112-117
        • Gaddam K.
        • Pimenta E.
        • Thomas S.J.
        • et al.
        Spironolactone reduces severity of obstructive sleep apnoea in patients with resistant hypertension: a preliminary report.
        J Hum Hypertens. 2010; 24: 532-537
        • Yang L.
        • Zhang H.
        • Cai M.
        • et al.
        Effect of spironolactone on patients with resistant hypertension and obstructive sleep apnea.
        Clin Exp Hypertens. 2016; 38: 464-468
        • Yilmaz F.
        • Ozyildirim S.
        • Talay F.
        • Karaaslan K.
        • Gunduz H.
        Obstructive sleep apnea as a risk factor for cardiovascular diseases.
        Cardiol J. 2007; 14: 534-537
        • Krasinska B.
        • Miazga A.
        • Cofta S.
        • et al.
        Effect of eplerenone on the severity of obstructive sleep apnea and arterial stiffness in patients with resistant arterial hypertension.
        Pol Arch Med Wewn. 2016; 126: 330-339
        • Bazzano L.A.
        • Khan Z.
        • Reynolds K.
        • He J.
        Effect of nocturnal nasal continuous positive airway pressure on blood pressure in obstructive sleep apnea.
        Hypertension. 2007; 50: 417-423
        • Montesi S.B.
        • Edwards B.A.
        • Malhotra A.
        • Bakker J.P.
        The effect of continuous positive airway pressure treatment on blood pressure: a systematic review and meta-analysis of randomized controlled trials.
        J Clin Sleep Med. 2012; 8: 587-596
        • Lorenzi-Filho G.
        • Almeida F.R.
        • Strollo P.J.
        Treating OSA: current and emerging therapies beyond CPAP.
        Respirology. 2017; 22: 1500-1507
        • Tietjens J.R.
        • Claman D.
        • Kezirian E.J.
        • et al.
        Obstructive sleep apnea in cardiovascular disease: a review of the literature and proposed multidisciplinary clinical management strategy.
        J Am Heart Assoc. 2019; 8e010440
        • Chaouat A.
        • Weitzenblum E.
        • Krieger J.
        • Oswald M.
        • Kessler R.
        Pulmonary hemodynamics in the obstructive sleep apnea syndrome. Results in 220 consecutive patients.
        Chest. 1996; 109: 380-386
        • Wang E.
        • Chomsky-Higgins K.
        • Chen Y.
        • et al.
        Treatment of primary aldosteronism reduces the probability of obstructive sleep apnea.
        J Surg Res. 2019; 236: 37-43
        • Conn J.W.
        • Cohen E.L.
        • Rovner D.R.
        • Nesbit R.M.
        Normokalemic primary aldosteronism. a detectable cause of curable "essential" hypertension.
        JAMA. 1965; 193: 200-206
        • Mulatero P.
        • Stowasser M.
        • Loh K.C.
        • et al.
        Increased diagnosis of primary aldosteronism, including surgically correctable forms, in centers from five continents.
        J Clin Endocrinol Metab. 2004; 89: 1045-1050