Diagnostics and Subtyping in Primary Aldosteronism

Primary Aldosteronism (PA), a condition characterized by autonomous and excessive production of aldosterone from one or both adrenal gland(s), is now recognised as a prevalent secondary cause of hypertension associated with high cardiometabolic risk. Identification and subtyping of PA is important to allow institution of targeted management (eg., medical therapy with mineralocorticoid receptor antagonist in bilateral PA or surgery in unilateral subtype) for risk reduction and potential cure (in case of unilateral PA). Recent guidelines from the Endocrine Society (USA) and the European Society of Society suggest a routine screening of PA in all patients with hypertension. A number of novel diagnostic approaches are emerging to streamline identification and subtyping of PA. This Research Topic aims to publish original research and review articles reporting the advances and controversies in the diagnosis and subtyping of PA.

Proposed topics include, but are not limited to:

• Epidemiology and Clinical Impact
- Prevalence and clinical burden of PA in hypertensive populations

• Screening and Diagnostic Strategies
- Optimization of the aldosterone-to-renin ratio (ARR): analytical and pre-analytical considerations
- Role and interpretation of confirmatory tests in the diagnostic algorithm
- Real-world challenges and solutions in early case detection

• Subtyping Approaches
- Advances in adrenal imaging techniques (CT, MRI, functional imaging)
- Adrenal vein sampling (AVS): technical developments, standardization efforts, and limitations
- Emerging non-invasive methods for subtyping, including steroid profiling, machine learning, and biomarker-based strategies

• Novel Diagnostic Tools and Biomarkers
- Application of steroid metabolomics and mass spectrometry in PA work-up
- Genetic testing for familial and somatic mutations associated with PA
- Integration of artificial intelligence and clinical prediction models for diagnostic refinement

• Therapeutic Strategies and Outcomes
- Surgical management of unilateral PA: patient selection, outcomes, and predictors of cure
- Optimization of medical therapy with mineralocorticoid receptor antagonists in bilateral PA
- Novel therapeutic approaches and precision medicine perspectives

• Guidelines, Implementation, and Controversies
- Critical appraisal of recent international guidelines (e.g., Endocrine Society)
- Barriers to implementation of screening and diagnostic algorithms in routine practice
- Cost-effectiveness analyses and health system implications

• Future Directions
- Integration of multi-omics, advanced imaging, and clinical data for personalized management
- Long-term cardiovascular and renal outcomes following targeted interventions
- Perspectives on population-based screening and preventive strategies