Mineralocorticoid Receptor Antagonist Discontinuation in Adrenal Venous Sampling for Subtyping Patients With Primary Hyperaldosteronism: A Systematic Review and Meta-Analysis

Background: Adrenal venous sampling (AVS) interpretation distinguishes unilateral from bilateral primary aldosteronism (PA), which determines surgical versus lifelong medical management. Data is scant regarding the effects of mineralocorticoid receptor antagonist (MRA) use on the risk of AVS misclassification. Objectives: To review the data in the literature about the effect of uninterrupted MRA use on the success of AVS lateralization and postoperative clinical and biochemical outcomes in patients with PA. Methods: A systematic search of five different databases (PubMed, Embase, Scopus, Web of Science, Cochrane Library) with no time restrictions was performed to identify relevant studies evaluating patients with PA who underwent AVS while on or off concurrent MRA treatment. Results: Four retrospective cohort studies were included, yielding a total of 1116 participants who underwent AVS. Of these, 147 (13.2%) were performed with concurrent MRA therapy. Rates of successful AVS were higher in patients with ongoing (89.1%) versus discontinued (78.0%) MRA treatment, with continuation of MRAs associated with a higher likelihood of lateralization consistent with unilateral disease (OR = 2.1, 95% CI: 1.4–3.1, I² = 0%). Clinical (OR = 0.9, 95% CI: 0.1–10.7, I² = 53%) and biochemical (OR = 0.8, 95% CI: 0.2–3.1, I² = 47%) success rates were comparable between MRA and non-MRA groups. Conclusion: Concurrent use of MRA treatment did not adversely affect the diagnostic performance of AVS, rates of PA lateralization or postoperative outcomes. These results suggest that discontinuation of MRAs, despite being recommended by society guidelines, may not be necessary, and instead support a patient-centred approach to management of PA. Given the overall low quality of evidence, future prospective studies are needed to address this dilemma.