Hyperaldosteronism Endocrine Society Practice Quiz

hyperaldosteronism practice quiz endo guidelines

1. In which patients do we recommend case detection of primary aldosteronism (PA)?

a. Patients with hypertension only

b. Patients with hypokalemia only

c. Patients with hypertension and spontaneous or diuretic-induced hypokalemia

d. Patients with hypotension and a family history of early onset hypertension

e. None of the above

2. What is the plasma aldosterone/renin ratio (ARR) used for in the detection of PA?

a. To confirm the diagnosis of PA

b. To subtype PA

c. To detect possible cases of PA

d. To identify patients who do not have PA

e. None of the above

3. What do we recommend for patients with a positive ARR?

a. Proceed directly to subtype classification

b. Undergo one or more confirmatory tests to definitively confirm or exclude the diagnosis

c. No further testing is necessary

d. Treat with medical therapy immediately

e. None of the above

4. In the setting of spontaneous hypokalemia, plasma renin below detection levels plus plasma aldosterone concentration (PAC) >20 ng/dL (550 pmol/L), is there a need for further confirmatory testing?

a. Yes

b. No

5. What do we recommend for patients with documented unilateral primary aldosteronism (APA or UAH)?

a. Medical treatment including a mineralocorticoid receptor antagonist (MR antagonist)

b. Proceed directly to subtype classification

c. Undergo one or more confirmatory tests

d. Unilateral laparoscopic adrenalectomy

e. None of the above

6. When is medical treatment with an MR antagonist recommended for patients with PA?

a. When a patient is unwilling or unable to undergo further investigations

b. When a patient has bilateral PA

c. When a patient has unilateral PA

d. When a patient has a positive ARR

e. None of the above

7. When is adrenal venous sampling (AVS) recommended to make the distinction between unilateral and bilateral adrenal disease?

a. When surgical treatment is not feasible

b. When a patient has a positive ARR

c. When a patient is younger than 35 years old

d. When surgical treatment is feasible and desired by the patient

e. None of the above

8. What is the recommended blood pressure level for case detection of primary aldosteronism (PA)?

A) Sustained blood pressure above 130/80 mm Hg

B) Sustained blood pressure above 140/90 mm Hg

C) Sustained blood pressure above 150/100 mm Hg

D) Sustained blood pressure above 160/110 mm Hg

E) Sustained blood pressure above 170/120 mm Hg

9. What is the most common presentation of primary aldosteronism (PA)?

A) Hypokalemic hypertension

B) Normokalemic hypertension

C) Hyperkalemic hypertension

D) Hypotension

E) Hypertension with bradycardia

10. What is the recommended confirmatory test for patients with a positive plasma aldosterone/renin ratio (ARR) for primary aldosteronism (PA)?

A) Adrenal computed tomography (CT)

B) Adrenal venous sampling (AVS)

C) Magnetic resonance imaging (MRI)

D) Ultrasound

E) Positron emission tomography (PET)

11. What is the preferred treatment for patients with documented unilateral primary aldosteronism (PA)?

A) Medical treatment with a mineralocorticoid receptor antagonist

B) Medical treatment with a beta-blocker

C) Bilateral laparoscopic adrenalectomy

D) Unilateral laparoscopic adrenalectomy

E) Radiation therapy

12. What is the prevalence of primary aldosteronism (PA) in hypertensive patients?

A) Less than 1%

B) Between 1% and 5%

C) More than 5%

D) More than 10%

E) More than 15%

13. When should blood samples for the ARR test be collected?

a. After dinner

b. After patients have been out of bed for at least 2 hours

c. Right after patients wake up

d. During lunchtime

e. When patients have been out of bed for less than 2 hours

14. What should be the patient's dietary salt intake before the ARR test?

a. It should be restricted.

b. It should be encouraged.

c. It should be unchanged.

d. It should be increased.

e. It should be low.

15. How long should MR antagonists be withdrawn before ARR testing?

a. At least 2 weeks

b. At least 4 weeks

c. At least 6 weeks

d. At least 8 weeks

e. There is no need to withdraw MR antagonists.

16. What is the suggested approach for collecting blood samples for the ARR test?

a. Collect blood in the afternoon, after the patient has been out of bed for at least 2 hours.

b. Collect blood with a Vacutainer to minimize the risk of spuriously raising potassium.

c. Maintain sample on ice during delivery to the laboratory.

d. Collect blood carefully, avoiding stasis and hemolysis.

e. Separate plasma from cells within 60 minutes of collection.

17. Which medication has a minimal effect on plasma aldosterone levels and can control hypertension during case finding and confirmatory testing for PA?

a. Propranolol

b. Atenolol

c. Lisinopril

d. Verapamil slow-release

e. Hydrochlorothiazide

18. What is the recommended time of day for collecting blood for ARR testing?

a) Late afternoon

b) After the patient has been sitting for at least 5-15 minutes

c) Early morning before getting out of bed

d) Mid-morning after the patient has been sitting for at least 2 hours

e) Late evening

19. Which of the following medications should be withdrawn for at least 4 weeks before ARR testing?

a) Verapamil slow-release

b) Hydralazine

c) Doxazosin mesylate

d) Spironolactone

e) Prazosin hydrochloride

20. What is the usual dose of verapamil slow-release for controlling hypertension during case finding and confirmatory testing for PA?

a) 10-12.5 mg twice daily

b) 0.5-1 mg two or three times daily, increasing as required

c) 1-2 mg once daily, increasing as required

d) 90-120 mg twice daily

e) 1-2 mg twice daily

21. What is the recommended cutoff value for PAC in the screening criteria for PA?

a) 10 ng/dL (280 pmol/L)

b) 15 ng/dL (410 pmol/L)

c) 20 ng/dL (550 pmol/L)

d) 25 ng/dL (690 pmol/L)

e) 30 ng/dL (830 pmol/L)

22. What is the minimum sensitivity required for renin assays when measuring the ARR?

A. 0.5 ng/mL/h (PRA)

B. 5 ng/L (DRC)

C. 1 ng/mL/h (PRA)

D. 2 ng/L (DRC)

E. 0.2 ng/mL/h (PRA) or 2 mU/L (DRC)

23. Which method of measuring plasma aldosterone levels is the most reliable?

A. Radioimmunoassay (RIA)

B. Enzyme-linked immunosorbent assay (ELISA)

C. Tandem mass spectrometry (MS/MS)

D. Chemiluminescence immunoassay (CLIA)

E. Fluorescence immunoassay (FIA)

24. What is a limitation of the ARR in the presence of very low renin levels?

A. It may be falsely elevated even when plasma aldosterone is low.

B. It may be falsely low even when plasma aldosterone is high.

C. It cannot be interpreted when renin levels are low.

D. It is not affected by low renin levels.

E. It can only be interpreted when renin levels are very high.

25. How do some investigators proceed with a diagnostic workup for PA in patients with elevated ARR and low PAC?

A. They immediately proceed with surgery to remove the affected adrenal gland.

B. They wait for PAC to increase before proceeding with further testing.

C. They only proceed with a diagnostic workup if the patient has other symptoms.

D. They proceed with a diagnostic workup for PA in all patients with elevated ARR.

E. They proceed with a diagnostic workup only if the PAC is below the level used to define normal suppression during confirmatory suppression testing.

26. Why is there substantial variability in cutoff values for the ARR?

A. Because of differences in diagnostic protocols

B. Because of differences in assay methods

C. Because of differences in patient populations

D. Because of differences in interpretation criteria

E. Because of differences in sample collection techniques

27. Which of the following is true regarding the "gold standard" confirmatory test for PA?

a) There is a single test that is optimal

b) There is no definitive evidence for an optimal test

c) The captopril challenge test is the most reliable

d) The fludrocortisone suppression test is the most reliable

e) All confirmatory tests have a similar degree of sensitivity and specificity

28. What is the recommended initial testing for patients with a positive ARR for PA?

a) Proceed directly to subtype classification

b) Repeat the ARR test

c) Undergo one or more confirmatory tests

d) Start anti-hypertensive medication

e) None of the above

29. What is the recommended approach to diagnosing PA in patients with spontaneous hypokalemia, plasma renin below detection levels, and PAC >20 ng/dL?

a) Proceed directly to subtype classification

b) Undergo a single confirmatory test

c) Undergo multiple confirmatory tests

d) No need for further confirmatory testing

e) Repeat the ARR test

30. What cutoff value was found for the aldosterone-cortisol ratio in the prospective Primary Aldosteronism Prevalence in Hypertensives study?

a) 6.0 ng/dL

b) 6.8 ng/dL

c) 7.0 ng/dL

d) 7.5 ng/dL

e) 8.0 ng/dL

31. Which test has shown to have similar accuracy as the captopril challenge test when performed under adequate sodium intake conditions?

a) Fludrocortisone suppression test

b) Oral sodium loading test

c) Saline infusion test

d) Furosemide upright test

e) None of the above

32. What is the initial test recommended for subtype testing of patients with PA?

a. Aldosterone to renin ratio

b. CT scan

c. MRI

d. Adrenal venous sampling

e. None of the above

33. Which of the following is a limitation of adrenal CT in the subtype evaluation of PA?

a. False positives for IAH

b. Inability to visualize microadenomas

c. Difficulty distinguishing between unilateral and bilateral disease

d. Risk of adrenal hemorrhage

e. All of the above

34. What is the gold standard test to distinguish unilateral from bilateral forms of PA in patients who are candidates for surgery?

a. Aldosterone to renin ratio

b. CT scan

c. MRI

d. Adrenal venous sampling

e. None of the above

35. What is the purpose of adrenal venous sampling (AVS) in the diagnosis of primary aldosteronism (PA)?

A. To determine blood glucose levels

B. To measure levels of insulin and glucagon

C. To assess cortisol and aldosterone levels in both adrenal veins and a peripheral vein

D. To measure levels of catecholamines in the adrenal glands

E. To assess thyroid hormone levels in the adrenal glands

36. What is the typical ratio of adrenal vein to peripheral vein cortisol concentrations in AVS?

A. Less than 1

B. Less than 2

C. More than 2

D. More than 5

E. More than 10

37. Which test may be used in patients with unsuccessful AVS and a CT scan showing a unilateral adrenal mass?

A. Thyroid function test

B. Posture stimulation test

C. Oral glucose tolerance test

D. Electrocardiogram

E. Urine drug screen

38. What is the purpose of (11)C-metomidate positron emission tomography-computed tomography in the diagnosis of PA?

A. To measure insulin and glucagon levels in the adrenal glands

B. To assess thyroid hormone levels in the adrenal glands

C. To determine blood glucose levels in the adrenal glands

D. To measure levels of catecholamines in the adrenal glands

E. To distinguish between aldosterone-producing adenomas and other types of adrenal tumors

39. When should genetic testing be considered in the diagnosis of PA?

A. In all patients with hypertension

B. In patients with confirmed PA who are older than 60 years of age

C. In patients with confirmed PA who have a family history of diabetes

D. In patients with an onset of confirmed PA earlier than 20 years of age and in those who have a family history of PA or strokes at a young age

E. In patients with confirmed PA who have a history of smoking

40. What is the purpose of adrenal venous sampling (AVS) in the diagnosis of primary aldosteronism (PA)?

A. To determine blood glucose levels

B. To measure levels of insulin and glucagon

C. To assess cortisol and aldosterone levels in both adrenal veins and a peripheral vein

D. To measure levels of catecholamines in the adrenal glands

E. To assess thyroid hormone levels in the adrenal glands

41. What is the typical ratio of adrenal vein to peripheral vein cortisol concentrations in AVS?

A. Less than 1

B. Less than 2

C. More than 2

D. More than 5

E. More than 10

42. What is the purpose of (11)C-metomidate positron emission tomography-computed tomography in the diagnosis of PA?

A. To measure insulin and glucagon levels in the adrenal glands

B. To assess thyroid hormone levels in the adrenal glands

C. To determine blood glucose levels in the adrenal glands

D. To measure levels of catecholamines in the adrenal glands

E. To distinguish between aldosterone-producing adenomas and other types of adrenal tumors

43. When should genetic testing be considered in the diagnosis of PA?

A. In all patients with hypertension

B. In patients with confirmed PA who are older than 60 years of age

C. In patients with confirmed PA who have a family history of diabetes

D. In patients with an onset of confirmed PA earlier than 20 years of age and in those who have a family history of PA or strokes at a young age

E. In patients with confirmed PA who have a history of smoking

44. What is the recommended treatment for patients with documented unilateral PA?

a. Medical treatment including a MR antagonist

b. Bilateral laparoscopic adrenalectomy

c. Unilateral laparoscopic adrenalectomy

d. Watchful waiting

e. Radiation therapy

45. What is the cure rate for hypertension in patients with APA after unilateral adrenalectomy?

a. 10%

b. 35%

c. 50%

d. 70%

e. 90%

46. What is the main cause of death in patients with PA?

a. Chronic kidney disease

b. Stroke

c. Myocardial infarction

d. Arrhythmias

e. All of the above

47. Which factors are associated with hypertension resolution in the postoperative period after adrenalectomy?

a. Coexistent primary hypertension (of unknown cause)

b. Older age and/or longer duration of hypertension

c. Positive preoperative response to spironolactone

d. Duration of hypertension <5 years

e. All of the above

48. Why is laparoscopic adrenalectomy preferred over other methods of treatment in patients with unilateral adrenal disease?

a. It is associated with fewer complications and shorter hospital stays

b. It can either eliminate the need for medication or reduce medication-related side effects

c. It can cure or improve hypertension and hypokalemia

d. It can reduce cardiovascular morbidity

e. All of the above

49. What is the recommended postoperative management for patients who undergo surgery for primary aldosteronism?

a) Clinicians should measure plasma aldosterone and renin activity levels long after surgery.

b) Clinicians should withdraw potassium supplementation before surgery.

c) Clinicians should discontinue spironolactone before surgery.

d) Clinicians should measure plasma aldosterone and renin activity levels shortly after surgery.

e) Clinicians should recommend a low-sodium diet after surgery.

50. What type of fluids should be used for postoperative IV hydration?

a) Normal saline with potassium chloride

b) Dextrose solution

c) Lactated Ringer's solution

d) Normal saline without potassium chloride

e) It depends on the patient's individual case

51. What is the recommended treatment for patients with PA due to bilateral adrenal disease?

a) Surgery

b) Medical treatment with a thiazide diuretic

c) Medical treatment with an MR antagonist

d) Both surgery and medical treatment with an MR antagonist

e) None of the above

52. Which agent has been the agent of choice for medical treatment of PA for more than five decades?

a) Amiloride

b) Triamterene

c) Eplerenone

d) Spironolactone

e) None of the above

Download the pdf below for detailed explanations of all answers.

Primary Hyperaldosteronism Guideline Practice Quiz

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Hyperaldosteronism Guideline Practice Quiz

This was first published on February 18, 2023 and Last Updated on March 16, 2023 by MyEndoConsult

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