Nationwide, Pragmatic, Direct-to-Patient Primary Aldosteronism Testing Program.

Summary

In a nationwide pragmatic program (n=694), 25.4% of hypertensive adults screened positive for primary aldosteronism through direct-to-patient testing, despite 57% already being under specialist care. Among positives, 13.7% initiated aldosterone-targeted therapy and 24.5% reported improved blood pressure, demonstrating feasibility and clinical yield of scalable remote screening.

Key Findings

• 25.4% of 694 hypertensive participants screened positive for primary aldosteronism using a standardized, direct-to-patient algorithm.
• Despite specialty care (endocrinology/cardiology/nephrology) in 57% of participants, most had not previously been tested for primary aldosteronism.
• Among those with positive results, 25.5% underwent additional testing, 13.7% started aldosterone-targeted therapy, and 24.5% reported improved blood pressure.
• Common indications for testing were sleep apnea, resistant hypertension, and hypokalemia; over half had ≥2 indications.

Clinical Implications

Health systems can adopt direct-to-patient workflows (remote consent, local labs, standardized interpretation) to increase primary aldosteronism detection and expedite mineralocorticoid receptor antagonist use or surgical referral. Primary care and specialty clinics should integrate streamlined testing for patients with resistant hypertension, hypokalemia, or sleep apnea.

Limitations

• Nonrandomized design with potential selection bias from online recruitment.
• Incomplete uptake of downstream confirmatory testing and therapy; outcomes limited to 6–12 months follow-up.

Future Directions

Head-to-head comparisons of direct-to-patient versus clinic-based workflows, cost-effectiveness analyses, and integration with electronic health record prompts to scale universal primary aldosteronism screening.