Primary aldosteronism: New PA screening guidelines for patients with hypertension
    

Primary aldosteronism (PA) is a hormonally driven form of secondary hypertension caused by excess aldosterone production from one or both adrenal glands.¹ Characterized by high aldosterone levels and suppressed renin activity, it is treatable when detected.

By adopting a simplified, new test strategy, supported by the latest PA and hypertension guidelines, healthcare providers can bridge the gap in care and significantly improve patient outcomes. 

In this article:

Clinical challenge | Why it matters | Ordering recommendations | Interpreting test results | Next steps | Supporting resources

Clinical challenge: A common condition hiding in plain sight

PA affects nearly 30% of people with high blood pressure,² making it much more common than once believed. Still, fewer than 1% of the 120 million Americans with hypertension are screened for it.^3,4 This points to a major gap in diagnosis and care.

The consequences of underdiagnosis are significant. Left untreated, PA can drive cardiovascular and kidney complications more aggressively than essential hypertension. Perceived complexity of testing, lack of awareness, and low confidence in results have all contributed to the gap in diagnosis. These drawbacks have been addressed by updated test strategies.

The high prevalence of PA in hypertension patients reveals a need for broader screening of the condition as well as improved testing options. Fortunately, a new screening protocol has removed barriers and simplified testing for primary care.  Additionally, the 2025 Endocrine Society clinical practice guidelines on primary aldosteronism now recommend that all patients with hypertension be screened for PA.⁵

Why it matters: The high cost of a missed diagnosis

Primary aldosteronism is not just another form of high blood pressure. It comes with a disproportionately higher risk of serious health complications. Compared to patients with essential hypertension, those with untreated PA face elevated risks of^1,6

• Atrial fibrillation
• Heart disease
• Heart failure
• Kidney disease
• Metabolic disease
• Myocardial infarction
• Sleep apnea
• Stroke
• Type 2 diabetes mellitus

PA can be easily managed, making a timely, accurate diagnosis vital to improve patients’ quality of life and reduce long-term healthcare costs.

Ordering recommendations: PRA as a simple test to screen for PA 

Quest Diagnostics offers a reflex testing solution designed for improved ease of use: Plasma Renin Activity (PRA) with Reflex to Aldosterone. 

Recommended test: Plasma Renin Activity with Reflex to Aldosterone

• Test code: 13817
• CPT code: 84244
  Includes test code 16846: Plasma Renin Activity, LC/MS/MS. If renin is suppressed (<1 ng/mL/h), aldosterone is automatically measured (test code 17181).

This test does not require withholding of blood pressure medications, with the exception of mineralocorticoid receptor antagonists (MRAs).

PRA screening is recommended for patients with hypertension. This includes new-onset hypertension, controlled hypertension, and severe or resistant hypertension. It is also recommended for those with a strong family history of hypertension. 

The Plasma Renin Activity with Reflex to Aldosterone test requires a single blood draw, minimizing patient burden and offering a clearer diagnostic picture sooner.

Testing considerations

The Endocrine Society guidelines also include the following pretesting considerations:

• Assess potassium levels if not performed recently, as low potassium may lead to a false positive for low aldosterone
• The patient should halt MRA use for 4 weeks prior to the test to avoid interference

Related tests

Aldosterone/Plasma Renin Activity Ratio, LC/MS/MS

• Test code: 16845
• CPT code: 82088, 84244

Potassium, Serum

• Test code: 733
• CPT code: 84132

Interpreting test results with a simple algorithm

Quest’s reflex algorithm simplifies clinical interpretation by providing a tiered approach based on PRA suppression and aldosterone concentration.

If renin is not suppressed, PA is unlikely. If renin is suppressed, aldosterone levels determine next steps. This model streamlines clinical decision-making and reduces false negatives that might result from relying solely on ARR.

PRA test interpretation

IF, the result of Plasma Renin Activity (PRA) is suppressed (i.e., ≤ 1 ng/mL/min)

AND, the result of aldosterone is ≥ 7.5 ng/mL

AND, the ARR value is > 15

THEN, the patient meets criteria for PA based on the 2025 Endocrine Society clinical practice guidelines.

Clinical categories of PA

Aldosterone levels can be used to place PA patients into 2 clinical categories as follows:

• Aldosterone levels ≥ 7.5: primary aldosteronism confirmed if ARR > 15
• Aldosterone levels < 7.5: primary aldosteronism unlikely, suggesting low renin hypertension

Test selection and interpretation, diagnosis, and patient management decisions should be made based on the physician’s education, clinical expertise, and assessment of the patient.

Next steps: From test to treatment

If a PA diagnosis is likely based on the algorithm, providers may consider adding an MRA to their patient’s current regimen for 4 weeks, with comparative blood pressure readings at the start and at 4 weeks to evaluate response.  

Referral to an endocrinologist or hypertension specialist may also be considered for confirmatory testing, subtyping, and treatment planning. Depending on subtype and severity, treatment may include the following:⁴

• Mineralocorticoid receptor antagonists
• Adrenal computed tomography or adrenal vein sampling
• Possible surgical intervention (eg, laparoscopic adrenalectomy)

Consult the full practice guidelines for more detailed information.

Quest also offers clinical algorithms, interpretation guides, and consultation with endocrinology specialists to support providers’ next-step decision-making for patients with PA. Call 1.866.MYQUEST to speak directly with a specialist.

Supporting resources