Figure 1.

Expanded algorithm for triaging patients with positive screen for PA. Importantly, MRA is the treatment of choice in those with positive screens but negative confirmatory testing. For patients who are surgical candidates, CT scan and dexamethasone suppression testing (DST) (order can be inverted) precede the decision to recommend AVS, which incorporates the likelihood of lateralization and of significant clinical benefit from adrenalectomy. The likelihood stratification step is admittedly an imprecise and nuanced exercise, but as more outcomes data are reported and decision tools developed, the confidence in this process will increase. Even after a normal DST result, MRA therapy (dashed arrow) remains an option if AVS expertise is not available or if other factors create reluctance for the patient or endocrinologist to pursue AVS next. Patients with an adrenal cortical adenoma, particularly if >2 cm in diameter plus low ACTH and other convincing evidence of hypercortisolemia are sent to adrenalectomy, and the PA is reassessed postoperatively. For adrenal masses with suspicious features (large size, necrosis, high density, irregular borders), evaluation for adrenocortical carcinoma (ACC) is warranted. Whenever MRA therapy is used, including after a bilateral result from AVS, periodic reassessment is indicated, and AVS should be reconsidered if response to MRA is inadequate or is worsening of PA is identified. A cortisol of 50 nmol/L is 1.8 μg/dL; an aldosterone of 100 pmol/L is 4 ng/dL. Abbreviations: AVS, adrenal vein sampling; CT, computed tomography; MRA, mineralocorticoid-receptor antagonist; PA, primary aldosteronism.