Background: Primary aldosteronism (PA), a primary adrenal disorder leading to excessive aldosterone production by one or both adrenal glands, is a common cause of hypertension. It is associated with an increased risk of cardiovascular complications compared with primary hypertension. Despite effective methods for diagnosing and treating PA, it remains markedly underdiagnosed and undertreated.

Objective: To develop an updated guideline that provides a practical, clinical approach to identifying and managing PA to improve diagnosis rates and encourage targeted treatment.

Methods: The Guideline Development Panel (GDP), composed of a multidisciplinary panel of clinical experts and experts in systemic review methodology, used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to define 10 questions related to the diagnosis and treatment of PA. Systematic reviews were conducted for each question. The GDP used the GRADE Evidence to Decision (EtD) framework to consider contextual factors, such as stakeholder values and preferences, costs and required resources, costeffectiveness, acceptability, feasibility, and the potential impact on health equity.

Results: We suggest that all individuals with hypertension be screened for PA by measuring aldosterone and renin and determining the aldosterone to renin ratio, and that subsequent clinical care be guided by the results. We suggest that individuals with PA receive PA-specific therapy, either medical or surgical. In individuals who screen positive for PA, we suggest (1) commencement of PA-specific medical therapy in individuals who do not desire or are not candidates for surgery and in situations where the probability of lateralizing PA (excess aldosterone produced by one adrenal) is low based on screening results; and (2) aldosterone suppression testing in situations when screening results indicate an intermediate probability for lateralizing PA and individualized decision making confirms a desire to pursue eligibility for surgical therapy. In those who test positive by aldosterone suppression testing, and in those in whom screening results show a high probability of lateralizing PA (obviating the need for aldosterone suppression testing), we suggest adrenal lateralization with computed tomography scanning and adrenal venous sampling prior to deciding the treatment approach (medical vs surgical). In all individuals with PA and an adrenal adenoma, we suggest performing a 1-mg overnight dexamethasone suppression test. We suggest the use of mineralocorticoid receptor antagonists (MRAs) over epithelial sodium-channel (ENaC) inhibitors in the medical treatment of PA. We suggest the use of spironolactone over other MRAs, given its lower cost and greater availability; however, all MRAs, when titrated to equivalent potencies, are anticipated to have similar efficacy in treating PA. Thus, MRAs with greater mineralocorticoid receptor specificity and fewer androgen/progesterone receptormediated side effects may be preferred in some situations. In individuals receiving MRA therapy, we suggest monitoring renin and, in those whose hypertension remains uncontrolled and renin is suppressed, titrating the MRA to increase renin.

Conclusion: These recommendations provide a practical framework for the diagnosis and treatment of PA. They are based on currently available literature and take into consideration outcomes that are important to key stakeholders. The goal is to increase identification of individuals with PA and, by initiating PA-specific medical or surgical therapy, improve blood pressure control and reduce PA-associated adverse cardiovascular events. The guidelines also highlight important knowledge gaps in PA diagnosis and management.

背景： 原发性醛固酮增多症（PA）是一种导致单侧或双侧肾上腺过度分泌醛固酮的原发性肾上腺疾病，是高血压的常见病因。与原发性高血压相比，PA 与心血管并发症风险增加相关。尽管存在有效的诊断和治疗方法，但 PA 的诊断和治疗仍显著不足。

目的： 制定一份更新的指南，为识别和管理 PA 提供实用的临床方法，以提高诊断率并鼓励针对性治疗。

方法： 由多学科临床专家和系统评价方法学专家组成的指南制定小组（GDP）采用推荐分级的评估、制定与评价（GRADE）方法，界定了 10 个与 PA 诊断和治疗相关的问题。针对每个问题进行了系统评价。GDP 使用 GRADE 证据到决策（EtD）框架，考量了背景因素，例如利益相关者的价值观和偏好、成本与所需资源、成本效益、可接受性、可行性以及对健康公平的潜在影响。

结果：

筛查建议： 我们建议对所有高血压患者通过测量醛固酮和肾素水平并计算醛固酮/肾素比值（ARR）进行 PA 筛查，后续临床诊疗应依据筛查结果进行指导。

治疗原则： 我们建议确诊 PA 的患者接受 PA 特异性治疗（药物治疗或手术治疗）。

筛查阳性患者管理路径建议：

1. 直接药物治疗： 对于筛查结果提示单侧 PA（即一侧肾上腺分泌过多醛固酮）可能性较低的情况，以及对于不愿手术或不适合手术的患者，我们建议开始 PA 特异性药物治疗。

2. 醛固酮抑制试验： 对于筛查结果提示单侧 PA 可能性中等，且经个体化决策确认患者有意愿寻求符合手术治疗资格的情况，我们建议进行醛固酮抑制试验。

治疗决策前检查建议： 对于醛固酮抑制试验阳性者，以及筛查结果已明确提示单侧 PA 可能性高（无需再进行醛固酮抑制试验）者，我们建议在决定治疗方案（药物 vs 手术）前，通过计算机断层扫描（CT）和肾上腺静脉采血（AVS）进行肾上腺定位。

肾上腺腺瘤患者额外检查建议： 对于所有确诊 PA 并存在肾上腺腺瘤的患者，我们建议进行 1 mg 过夜地塞米松抑制试验。

药物选择建议： 在 PA 的药物治疗中，我们建议优先选择盐皮质激素受体拮抗剂（MRAs）而非上皮钠通道（ENaC）抑制剂。

MRA 选择建议： 考虑到较低的成本和更广泛的可用性，我们建议优先选择螺内酯而非其他 MRAs。然而，所有 MRAs 在滴定至同等效力剂量时，预期在治疗 PA 方面具有相似的疗效。因此，在特定情况下，可选择对盐皮质激素受体选择性更高、雄激素/孕激素受体介导副作用更少的 MRAs。

药物治疗监测建议： 对于接受 MRA 治疗的患者，我们建议监测肾素水平；对于高血压仍未控制且肾素受抑制的患者，建议增加 MRA 剂量以提高肾素水平。

结论： 这些建议为 PA 的诊断和治疗提供了一个实用框架。它们基于当前可用的文献，并考虑了关键利益相关者所关注的重要结局。其目标是提高 PA 患者的识别率，并通过启动 PA 特异性药物或手术治疗，改善血压控制，减少 PA 相关的不良心血管事件。该指南也强调了 PA 诊断和管理领域重要的知识空白。