Primary Aldosteronism Severity Score Predicts Treatment Success After Surgery or Medication
A new severity classification for primary aldosteronism reliably predicts lateralization and how well patients respond to treatment.
Summary
Primary aldosteronism (PA) is a common but underdiagnosed cause of high blood pressure driven by excess aldosterone from the adrenal glands. A new severity classification system called PASC groups patients into mild, moderate, or severe categories based on blood markers and clinical features. In a study of 833 PA patients across eight hospitals, higher PASC severity strongly predicted whether hormone overproduction was coming from one adrenal gland or both—a distinction critical for choosing surgery versus medication. Severe PA patients were far more likely to have one-sided disease but, paradoxically, less likely to achieve complete blood pressure cure after treatment. The findings support using PASC alongside the standard adrenal vein sampling procedure to better tailor treatment decisions and set realistic expectations for patients and clinicians.
Detailed Summary
Primary aldosteronism is the leading cause of secondary hypertension, affecting up to 10% of people with high blood pressure, yet it remains widely underdiagnosed and undertreated. Accurately determining whether excess aldosterone comes from one adrenal gland (unilateral) or both (bilateral) is essential because the treatment strategies—surgery versus lifelong medication—differ fundamentally. The 2025 clinical guidelines introduced a severity-stratified pathway to guide the use of adrenal venous sampling (AVS), but real-world validation of the underlying severity tool, the PA Severity Classification (PASC), was lacking.
This retrospective multicenter cohort study enrolled 833 PA patients who underwent AVS across eight tertiary centers in South Korea. Patients were classified as mild (6.1%), moderate (67.6%), or severe (26.2%) using PASC, which integrates biochemical and clinical parameters.
The results were striking. Higher PASC severity correlated in a stepwise fashion with AVS-confirmed unilateral (lateralizing) disease: 19.2% of mild, 48.0% of moderate, and 76.1% of severe patients had lateralizing PA. This gradient suggests PASC could help risk-stratify who most urgently needs AVS and who might reasonably skip it.
Treatment outcomes told a nuanced story. Among surgically treated unilateral PA patients, complete clinical success (blood pressure cure without medication) was achieved by 40.2% of moderate and 31.3% of severe patients—lower rates in more severe disease—though biochemical cure rates were similar across groups. In medically managed bilateral PA, complete clinical response fell sharply with severity: 36.8% (mild), 27.0% (moderate), and just 8.8% (severe). Biochemical normalization remained comparable.
These findings validate PASC as a clinically meaningful tool that not only predicts lateralization but also forecasts realistic treatment outcomes. Clinicians can use severity grading to counsel patients more accurately and design more personalized management plans. Caveats include the retrospective design and single-country setting, which may limit broader generalizability.
Key Findings
- 76% of severe PA patients had unilateral disease on AVS versus only 19% of mild PA patients.
- Complete blood pressure cure after surgery was lower in severe PA (31%) than moderate PA (40%).
- Medical treatment produced complete clinical response in only 8.8% of severe bilateral PA patients.
- Biochemical cure rates were similar across severity groups despite differing clinical outcomes.
- PASC severity classification reliably stratifies lateralization risk, supporting its use alongside AVS.
Methodology
Retrospective multicenter cohort study of 833 PA patients across eight South Korean tertiary centers, all of whom underwent adrenal venous sampling. Outcomes were assessed using validated PASO (surgical) and PAMO (medical) criteria. PASC severity was categorized as mild, moderate, or severe based on integrated biochemical and clinical features.
Study Limitations
This summary is based on the abstract only, as the full text was not available; some methodological details may be incomplete. The retrospective design introduces potential selection bias, and the exclusively South Korean tertiary-center population may limit generalizability to other ethnicities and healthcare settings. The relatively small proportion of mild PA cases (6.1%) may reduce statistical power for conclusions in that subgroup.
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