Case 1SB

49 yr old femaleObesityResistant hypertensionNormal K+Aldo 669 (23-415 pmol/L)Renin 8.2 (4-44 mU/L)ARR 81 (1-20)

CT (2011) – small low density lesion R adrenalUnchanged on repeat scan

Put on spironolactone after initial blood test by another physician – good BP response

How would you proceed?

Case 1SB

Medications altered – spiro stoppedDoxazosin added

Repeat bloods...............Aldo 689 (23-415 pmol/L)Renin 12.5 (4-44 mU/L)ARR 55 (1-20)

Is the diagnosis confirmed?

Case 1SB

IV saline suppression test

2 litres 0.9% saline over 4 hrsBloods pre and post

Aldosterone pre-test = 518 post-test = 346 pmol/L

normals should suppress < 50ng/l (140 pmol/L)Abnormal > 100 ng/L

Result confirms PA

How would you proceed?

Case 2BS

53 yr old femaleResistant hypertension for 10 yrs managed by GPLow K+ on several occasions, Na+ 144-148On 3 medications. BP clinic 180/100 (lower at home 140/80)

Aldo 258 (40-310 ng/L) (on meds including lisinopril and amlodipine)Renin 9.7 (4-44 mU/L)ARR 27

After altering meds and normalising K+.............................Aldo 494Renin 3ARR 165

CT Abdo – 2cm low density lesion L adrenal (normal looking R)

How would you proceed?

Case 2BS

AVS (difficult procedure)

cortisol AldoLeft adrenal >1750 1175

Right adrenal 543 194

IVC 468 815

How do you interpret these results?

How would you proceed?

Case 3MJ (Exeter patient)

55 yr old maleResistant hypertensionNormal K+Elevated aldo/renin and confirmed on salt loading

CT adrenals – no lesion identified

How might you proceed?

Case 3MJ (Exeter patient)

AVS results

Time site cortisol Aldosterone1530 L renal vein 321 3441530 Femoral vein 413 3891549 L adrenal vein 1350 9401550 Femoral vein 303 4321600 R adrenal vein 1674 310001602 Femoral vein 253 400

Left adrenal:femoral cortisol ratio 1350/303 = 4.5Right adrenal:femoral cortisol ratio 1674/253 = 6.6

Left adrenal aldosterone:cortisol ratio 940/1350 = 0.7Right adrenal aldosterone:cortisol ratio 31000/1674 = 18.5

Lateralisation ratio is 18.5/0.7 = 26.6