Maiolino Giuseppe, Rossitto Giacomo, Bisogni Valeria, Cesari Maurizio, Seccia Teresa Maria, Plebani Mario, Rossi Gian Paolo
Clinica dell'Ipertensione Arteriosa, and Laboratory Medicine, University of Padua, Italy.
Department of Medicine - DIMED, University of Padua, Italy.
J Am Heart Assoc. 2017 May 21;6(5):e005574. doi: 10.1161/JAHA.117.005574.
Current guidelines recommend use of the aldosterone-renin ratio (ARR) for the case detection of primary aldosteronism followed by confirmatory tests to exclude false-positive results from further diagnostic workup. We investigated the hypothesis that this could be unnecessary in patients with a high ARR value if the quantitative information carried by the ARR is taken into due consideration.
We interrogated 2 large data sets of prospectively collected patients studied with the same predefined protocol, which included the captopril challenge test. We used an unambiguous diagnosis of aldosterone-producing adenoma as reference index. We also assessed whether the post-captopril ARR and plasma aldosterone concentration fall furnished a diagnostic gain over baseline ARR values. We found that the false-positive rate fell exponentially, and, conversely, the specificity increased with rising ARR values. At receiver operating characteristics curves and diagnostic odds ratio analysis, the high baseline ARR values implied very high positive likelihood ratio and diagnostic odds ratio values. The baseline and post-captopril ARR showed similar diagnostic accuracy (area under the receiver operating characteristics curve) in both the exploratory and validation cohorts, indicating lack of diagnostic gain with this confirmatory test (between-area under the curve difference, 0.005; 95% CI, -0.031 to 0.040; =0.7 for comparison, and 0.05; 95% CI, -0.061 to 0.064; =0.051 for comparison, respectively).
These results indicate that the ARR conveys key quantitative information that, if properly used, can simplify the diagnostic workup, resulting in saving of money and resources. This can offer the chance of diagnosis and ensuing adrenalectomy to a larger number of hypertensive patients, ultimately resulting in better control of blood pressure.
当前指南推荐使用醛固酮-肾素比值（ARR）来筛查原发性醛固酮增多症，随后进行确诊试验以排除进一步诊断检查中的假阳性结果。我们研究了一个假设，即如果充分考虑ARR所携带的定量信息，对于ARR值高的患者可能无需进行确诊试验。
我们查询了两个前瞻性收集的患者大型数据集，这些患者按照相同的预定义方案进行研究，其中包括卡托普利激发试验。我们将明确诊断为醛固酮瘤作为参考指标。我们还评估了卡托普利激发试验后的ARR和血浆醛固酮浓度下降是否比基线ARR值具有诊断优势。我们发现假阳性率呈指数下降，相反，特异性随ARR值升高而增加。在受试者工作特征曲线和诊断比值比分析中，高基线ARR值意味着非常高的阳性似然比和诊断比值比。在探索性队列和验证性队列中，基线和卡托普利激发试验后的ARR显示出相似的诊断准确性（受试者工作特征曲线下面积），表明该确诊试验没有诊断优势（曲线下面积差值为0.005；95%可信区间为-0.031至0.040；比较的P值为0.7，以及0.05；95%可信区间为-0.061至0.064；比较的P值为0.051）。
这些结果表明，ARR传达了关键的定量信息，如果正确使用，可以简化诊断检查，从而节省资金和资源。这可以为更多高血压患者提供诊断及后续肾上腺切除术的机会，最终更好地控制血压。
