Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines’ inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown.
All hypertensive adult patients with obstructive sleep apnea (n=4,751) at one institution between 2012-2020 were compared to a control cohort without sleep apnea (n=117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation.
Obstructive sleep apnea patients were predominantly men and had higher BMI. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (OR 2.70; p<0.001) and hypokalemia (OR 1.26; p<0.001) independent of BMI, sex, and number of anti-hypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; p<0.001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% v. 4.6%; post-guidelines 3.6% v. 4.6%; p<0.01). Screening among eligible sleep apnea patients remained low before and after guideline publication (4.4% v. 3.4%).
Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.

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