Screening and Diagnosis Trends for Primary Aldosteronism: A Longitudinal Nationwide Cohort Study of 7.8 Million People

Abstract Background Primary aldosteronism (PA) is a common, treatable cause of hypertension for which screening is widely recommended but rarely performed in clinical practice. However, real-world screening and diagnosis patterns across the entire hypertensive population remain unknown. This study aimed to delineate the 22-year state of nationwide PA screening and diagnosis rates among all hypertensive population in Taiwan Methods In this nationwide retrospective cohort study from 2001 to 2022, we identified all patients with hypertension using a national health insurance database. We calculated annual PA screening and diagnosis rates, with particular focus on high-risk subgroups, including patients with resistant hypertension, early-onset hypertension, hypokalemia, and other comorbidities warranting screening. Results Among 7.8 million patients with hypertension, a total of 4.4% received PA screening during the study period. The annual PA screening rate increased from 0.26% in 2001 to 0.75% in 2022 ( p < 0.001) yet remained markedly low. In 2022, only 1.0% of patients with resistant hypertension, 3.0% with early-onset hypertension, and 3.6% with hypokalemia underwent screening. The diagnostic yield of PA showed a slight decrease over time, fluctuating between 8.0% and 6.7% ( p = 0.006). Conclusions Despite an increase in PA screening over the past two decades, absolute rates remain critically low, falling far short of guideline recommendations, especially in high-risk groups. Our findings quantify a major implementation gap between evidence and clinical practice. As international guidelines are shifting towards broader and simpler screening protocols, there is an urgent need to improve the detection of this common and actionable condition. Perspective What is known? Primary aldosteronism (PA) is a common, clinically important, and treatable cause of hypertension. Its adverse cardiovascular effects arise from renin independent aldosterone excess and chronic mineralocorticoid receptor overactivation. Current guidelines historically recommended screening only in high-risk groups, but recent expert consensus and international guidelines increasingly support broader and even universal screening among all hypertensive patients. Prior epidemiologic studies have examined PA screening almost exclusively within selected high-risk subgroups. No study has comprehensively evaluated real-world screening patterns across an entire hypertensive population. What is new? Using a 22-year nationwide cohort of nearly 8 million hypertensive patients, this is the first study to comprehensively quantify real-world trends in PA screening and diagnosis in Taiwan. Annual screening rates nearly tripled but remained profoundly low (<4%), even in guideline-recommended high-risk groups such as resistant hypertension, early-onset hypertension, and hypokalemia. Hypertensive patients receiving care at tertiary medical centers or in highly urbanized areas were more likely to undergo screening. What is next? The persistent under-screening of PA represents a major implementation gap, resulting in missed opportunities for targeted treatment and long-term cardiovascular risk reduction. Closing this gap will require a paradigm shift that includes broader screening strategies, decentralizing testing to primary care, and adopting simplified diagnostic pathways aligned with contemporary guidelines. Future efforts should evaluate the impact of these simplified approaches on diagnosis rates, treatment implementation, and cardiovascular outcomes, particularly as global practice moves toward earlier and more inclusive detection of renin-independent aldosteronism.

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