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2014 Pennsylvania Chapter Eastern Region Abstract Winner

2014 Pennsylvania Chapter Eastern Region Abstract Winner

Residents Clinical Vignette
First Place

Primary Hyperaldosteronism: Reassessing a "Negative" Work Up

Author: Jessica Schwartz, MD
Reading Hospital

Although previously thought to be a relatively rare cause of secondary hypertension, hyperaldosteronism is now believed to be present in 5-13% of cases making it the most common endocrine cause of uncontrolled blood pressure.

A 59 year-old male with 10 years of worsening resistant hypertension was seen at a specialist's office and noted to have a blood pressure of 219/122 mmHg. His hypertension had remained uncontrolled despite three medications, including a diuretic, which was discontinued due to persistent hypokalemia. Even off of the diuretic, the patient required potassium supplementation to maintain normokalemia. History included no tobacco use and good medication compliance. Workup to date had included a normal serum cortisol, 24-hour urine for catecholamines, renal duplex ultrasound, and an undetectable serum renin level (<0.06 ng/mL) leading to an EMR entry documenting "negative secondary hypertension workup". Upon discovery of this incomplete evaluation, a repeat renin with serum aldosterone found renin <0.06 ng/mL and aldosterone 26 ng/dL (normal: 8-20 ng/dL), aldosterone to renin ratio > 25 which led to an adrenal CT which discovered a 7mm nodule on the left adrenal gland. The patient was referred for definitive adrenal vein sampling and consideration for surgery.

As only 9-37% of patients demonstrate hypokalemia, a higher index of suspicion to test for aldosteronism should be uncontrolled hypertension. Correct identification of a secondary hypertension cause can lead to definitive therapy that can result in long-term hypertension control. Physicians caring for patients with resistant hypertension should review the previous 'workup' to re-consider whether hyperaldosteronism could have been overlooked as it was here.