Primary Hyperaldosteronism: Endocrine Society Guidelines

Management of Primary Hyperaldosteronism

Primary Hyperaldosteronism Guideline Quiz

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Primary Hyperaldosteronism Guideline Quiz

Primary Hyperaldosteronism: Endocrine Society Guidelines Primary Hyperaldosteronism Guideline Quiz

Primary Hyperaldosteronism Guideline Quiz

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1. Question
A 55-year-old female patient presents to the clinic with uncontrolled hypertension. Laboratory tests reveal a PAC of 18 ng/dL and PRA of 0.2 ng/mL/h. The patient is started on verapamil slow-release, but her blood pressure remains elevated. Which confirmatory test should be ordered to definitively confirm or exclude the diagnosis of PA?
- A) Oral sodium loading test
- B) Saline infusion test
- C) Fludrocortisone suppression test
- D) Captopril challenge test
Correct
Incorrect
2. Question
A 50-year-old male presents with hypertension that is controlled with lisinopril. The patient has a history of renal insufficiency with an estimated glomerular filtration rate (eGFR) of 30 ml/min/1.73m2. What is the most appropriate next step in management?
- A. Discontinue lisinopril and perform ARR testing
- B. Continue lisinopril and perform ARR testing
- C. Switch lisinopril to doxazosin mesylate and perform ARR testing
- D. Discontinue all antihypertensive medications for at least 2 weeks and perform ARR testing
Correct
Incorrect
3. Question
A 30-year-old female presents with hypertension that is controlled with amlodipine. The patient is interested in pursuing testing for primary aldosteronism. What is the most appropriate next step in management?
- A. Discontinue amlodipine for at least 2 weeks and perform ARR testing
- B. Start verapamil slow-release and monitor serum potassium levels
- C. Continue amlodipine and perform ARR testing
- D. Withdraw amlodipine for at least 4 weeks and perform ARR testing
Correct
Incorrect
4. Question
A 45-year-old male presents with hypertension that is resistant to multiple antihypertensive medications. The patient’s serum potassium is 2.8 mmol/L. What is the most appropriate next step in management?
- A. Start spironolactone and perform ARR testing
- B. Withdraw MR antagonists for at least 4 weeks and perform ARR testing
- C. Start verapamil slow-release and monitor serum potassium levels
- D. Initiate doxazosin mesylate and monitor serum potassium levels
Correct
Incorrect
5. Question
A 50-year-old man with hypertension is scheduled for an ARR test. He is also taking a beta-blocker medication. When should the beta-blocker medication be stopped before performing the ARR test?
- A. No need to stop the beta-blocker medication
- B. Stop the beta-blocker medication for at least 2 weeks before performing the ARR test
- C. Stop the beta-blocker medication for at least 4 weeks before performing the ARR test
- D. Stop the beta-blocker medication for at least 6 weeks before performing the ARR test
Correct
Incorrect
6. Question
A 60-year-old woman with hypertension is on a diuretic medication and has hypokalemia. When should the diuretic medication be stopped before performing an ARR test?
- A. No need to stop the diuretic medication
- B. Stop the diuretic medication for at least 2 weeks before performing the ARR test
- C. Stop the diuretic medication for at least 4 weeks before performing the ARR test
- D. Stop the diuretic medication for at least 6 weeks before performing the ARR test
Correct
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7. Question
A 55-year-old man with hypertension is scheduled for an ARR test. What is the best time of day to collect the blood sample?
- A. Early morning, before getting out of bed
- B. Late afternoon, after a full day of activity
- C. Midmorning, after being up for at least 2 hours and seated for 5-15 minutes
- D. Any time of day is acceptable for the ARR test
Correct
Incorrect
8. Question
A 45-year-old woman with hypertension has been taking spironolactone for the past year. What should be done before performing an ARR test?
- A. Nothing, the ARR test can be performed without any preparation
- B. Stop spironolactone for at least 2 weeks before performing the ARR test
- C. Stop spironolactone for at least 4 weeks before performing the ARR test
- D. Switch to a different antihypertensive medication that does not affect the ARR before performing the test
Correct
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9. Question
A 60-year-old woman with a history of hypertension presents with obstructive sleep apnea. What is the recommended next step in management?
- A) Perform a renin-aldosterone ratio (ARR) test
- B) Order a CT scan of the adrenal glands
- C) Refer the patient for adrenal vein sampling
- D) Monitor the patient with imaging and blood pressure measurements
Correct
Incorrect
10. Question
A 35-year-old man presents with hypertension and hypokalemia. What is the most likely cause of his symptoms?
- A) Primary aldosteronism
- B) Essential hypertension
- C) Secondary hypertension
- D) Isolated hypokalemia
Correct
Incorrect
11. Question
A 55-year-old woman is found to have an adrenal incidentaloma on imaging performed for an unrelated condition. She has a history of hypertension that is well-controlled with one antihypertensive medication. What is the recommended next step in management?
- A) Refer the patient for adrenal vein sampling
- B) Perform a renin-aldosterone ratio (ARR) test
- C) Order a CT scan of the adrenal glands
- D) Monitor the patient with imaging and blood pressure measurements
Correct
Incorrect
12. Question
A 45-year-old man presents with persistent hypertension despite treatment with three different antihypertensive medications, including a diuretic. His blood pressure is consistently above 150/100 mm Hg on multiple measurements. What is the next step in management?
- A) Refer the patient for adrenal vein sampling
- B) Perform a renin-aldosterone ratio (ARR) test
- C) Order a CT scan of the adrenal glands
- D) Increase the dose of the patient's current antihypertensive medications
Correct
Incorrect
13. Question
A 30-year-old male with primary adrenal insufficiency presents for genetic counseling. What type of PAI is inherited in an autosomal recessive pattern?
- a) Adrenoleukodystrophy
- b) Congenital adrenal hypoplasia
- c) Congenital hypogonadotropic hypogonadism
- d) APS-1
Correct
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14. Question
A 45-year-old female with primary adrenal insufficiency is diagnosed with autoimmune gastritis with vitamin B12 deficiency. What additional testing should be done during her annual evaluation?
- a) Serum sodium and potassium determinations
- b) Measurement of CYP11A1 autoantibodies
- c) Screening for tissue transglutaminase 2 autoantibodies
- d) Complete blood count
Correct
Incorrect
15. Question
A 10-year-old male with primary adrenal insufficiency presents for his annual follow-up appointment. What should be evaluated during this visit?
- a) Symptoms and signs of over- and under-replacement
- b) Screening for autoimmune diseases
- c) Patient education about sick day rules
- d) All of the above
Correct
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16. Question
A 35-year-old female with a history of primary adrenal insufficiency presents to the emergency department with severe abdominal pain and vomiting. What is the appropriate management in this situation?
- a) Continue the patient's regular steroid regimen
- b) Increase the patient's steroid dose by double the regular dose
- c) Administer 100 mg hydrocortisone via IM or IV injection immediately, followed by continuous infusion of 200 mg/24 hours
- d) Discharge the patient with instructions to follow up with their endocrinologist
Correct
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17. Question
What is the recommended best practice statement for the prevention of adrenal crisis in patients with primary adrenal insufficiency?
- A. Patient education concerning glucocorticoid adjustments in stressful events
- B. Use of a mineralocorticoid injection kit for emergency use
- C. Administration of rectal suppositories of mineralocorticoids for adrenal crisis prevention
- D. Increased oral fluid resuscitation during critical illness
Correct
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18. Question
What is the recommended duration of oral glucocorticoid dose at double or triple the usual daily dose for patients with primary adrenal insufficiency during febrile illness?
- A. 1-2 days
- B. 2-3 days
- C. 4-5 days
- D. 5-7 days
Correct
Incorrect
19. Question
In the absence of hydrocortisone, what glucocorticoid is suggested as an alternative for the treatment of adrenal crisis?
- A. Methylprednisolone
- B. Dexamethasone
- C. Prednisolone
- D. Fludrocortisone
Correct
Incorrect
20. Question
A patient with known primary adrenal insufficiency presents to the emergency department with symptoms of an adrenal crisis. What is the recommended immediate parenteral injection dose of hydrocortisone for adults?
- A. 25 mg
- B. 50 mg
- C. 75 mg
- D. 100 mg
Correct
Incorrect
21. Question
According to the revised 2015 guidelines, what is the current recommendation for referral by primary care physicians of patients with suspected PA?
- A. No referral is necessary
- B. Refer to a general endocrinologist
- C. Refer to a hypertension specialist
- D. Refer to a specialized center for further work-up
Correct
Incorrect
22. Question
A 55-year-old hypertensive patient presents to their primary care physician with sustained blood pressure readings of 160/100 mm Hg. According to the revised 2015 guidelines for the management of PA, what is the current recommendation for screening?
- A. No screening necessary
- B. Screen only if the patient has hypokalemia
- C. Screen only if the patient has a family history of PA
- D. Screen patients with sustained BP elevation above 150 mm Hg (systolic) and/or 100 mm Hg (diastolic)
Correct
Incorrect
23. Question
In patients with GRA, what is the first-line treatment recommended to lower ACTH and normalize BP and potassium levels?
- A. MR antagonist
- B. Calcium channel blocker
- C. Glucocorticoid
- D. Angiotensin-converting enzyme inhibitor
Correct
Incorrect
24. Question
Which of the following is a potential advantage of using amiloride as a mode of treatment for PA?
- A. Higher efficacy than spironolactone
- B. Lower cost than spironolactone
- C. Provides beneficial effects on endothelial function
- D. Reduces the risk of gynecomastia and erectile dysfunction in men
Correct
Incorrect
25. Question
A 30-year-old child with GRA is being treated with a glucocorticoid to suppress ACTH secretion. What is the recommended approach for determining treatment targets for BP?
- A) Use normative data for adults
- B) Determine targets based on symptoms
- C) Use normative data for children
- D) Use normative data for pediatric endocrine disorders
Correct
Incorrect
26. Question
A 40-year-old patient with glucocorticoid-remediable aldosteronism (GRA) is being treated with a synthetic glucocorticoid to suppress ACTH secretion. What is the recommended time of administration for the glucocorticoid?
- A) Morning
- B) Afternoon
- C) Evening
- D) Before bedtime
Correct
Incorrect
27. Question
A 35-year-old female patient with primary aldosteronism is being treated with spironolactone but is experiencing side effects such as menstrual irregularities. What is the alternative treatment option?
- A) Eplerenone
- B) Amiloride
- C) Angiotensin-converting enzyme inhibitor
- D) Triamterene
Correct
Incorrect
28. Question
A 55-year-old male patient with hypertension is diagnosed with primary aldosteronism. Which of the following is the first-line treatment recommended?
- A) Spironolactone
- B) Amiloride
- C) Angiotensin receptor blocker
- D) Calcium channel blocker
Correct
Incorrect
29. Question
A 55-year-old male presents with refractory hypertension despite treatment with multiple antihypertensive medications. Lab results reveal elevated aldosterone levels and low renin activity. CT scan shows a unilateral adrenal nodule. Which of the following is the most appropriate initial treatment for this patient?
- A) Laparoscopic adrenalectomy
- B) Spironolactone
- C) Eplerenone
- D) Triamterene
Correct
Incorrect
30. Question
A 50-year-old female with known bilateral adrenal nodules presents with persistent hypertension despite treatment with multiple antihypertensive medications. Lab results reveal elevated aldosterone levels and low renin activity. CT scan shows bilateral adrenal nodules. Which of the following is the most appropriate next step in management for this patient?
- A) Laparoscopic adrenalectomy
- B) Spironolactone
- C) Eplerenone
- D) Triamterene
Correct
Incorrect
31. Question
A 45-year-old male presents with refractory hypertension despite treatment with multiple antihypertensive medications. Lab results reveal elevated aldosterone levels and low renin activity. CT scan shows bilateral adrenal nodules. Which of the following is the most appropriate initial treatment for this patient?
- A) Laparoscopic adrenalectomy
- B) Spironolactone
- C) Eplerenone
- D) Triamterene
Correct
Incorrect
32. Question
What is the recommended treatment for patients with bilateral adrenal disease due to primary aldosteronism?
- a) Unilateral laparoscopic adrenalectomy
- b) Bilateral adrenalectomy
- c) Medical management with an MR antagonist
- d) Partial adrenalectomy
Correct
Incorrect
33. Question
What is the most common reason for persistently increased blood pressure after adrenalectomy for unilateral aldosterone-producing adenoma?
- a) Coexistent primary hypertension
- b) Multiple nodules in the extirpated adrenal gland
- c) Longer duration of hypertension
- d) Younger age at the time of surgery
Correct
Incorrect
34. Question
A patient with documented unilateral aldosterone-producing adenoma (APA) is recommended to undergo which of the following treatments?
- a) Medical management with an MR antagonist
- b) Partial adrenalectomy
- c) Unilateral laparoscopic adrenalectomy
- d) Bilateral adrenalectomy
Correct
Incorrect
35. Question
What is the effect of adrenalectomy on left ventricular mass index?
- a. No effect
- b. Decrease in left ventricular mass index
- c. Increase in left ventricular mass index
- d. Variable effect depending on the patient
Correct
Incorrect
36. Question
What is the cure rate for hypertension after unilateral adrenalectomy in patients with APA?
- a. Nearly 100%
- b. 50%
- c. 35-80%
- d. 56-77%
Correct
Incorrect
37. Question
A 35-year-old woman presents with hypertension and hypokalemia. Genetic testing shows a somatic mutation in the CACNA1D gene. What is the likely mechanism of action of this mutation?
- A. Activation of calcium channels
- B. Inhibition of the Na+/K+-ATPase pump
- C. Activation of the Na+/K+-ATPase pump
- D. Inhibition of calcium transport
Correct
Incorrect
38. Question
A 50-year-old man presents with hypertension and hypokalemia. Genetic testing shows a somatic heterozygous gain-of-function mutation in the ATP1A1 gene. What is the likely mechanism of action of this mutation?
- A. Activation of calcium channels
- B. Inhibition of the Na+/K+-ATPase pump
- C. Activation of the Na+/K+-ATPase pump
- D. Inhibition of calcium transport
Correct
Incorrect
39. Question
A 42-year-old woman presents with hypertension, hypokalemia, and elevated aldosterone levels. Genetic testing shows a mutation in the KCNJ5 gene. What is the likely diagnosis?
- A. Familial hyperaldosteronism type I
- B. Familial hyperaldosteronism type II
- C. Familial hyperaldosteronism type III
- D. Sporadic aldosterone-producing adenoma
Correct
Incorrect
40. Question
A 40-year-old male presents with hypertension and elevated aldosterone levels. He has no family history of hypertension. Which of the following genetic tests should be performed in this patient?
- A. Genetic testing for FH-I
- B. Genetic testing for FH-II
- C. Genetic testing for FH-III
- D. Genetic testing for somatic mutations in adrenal zona glomerulosa cells
Correct
Incorrect

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