A global real-world study assessing total time to adrenalectomy in primary aldosteronism

Background: Primary aldosteronism (PA) is a common treatable cause of hypertension. When caused by unilateral adrenal disease, it is potentially curable by adrenalectomy. However, specialized tests and other factors may delay definitive treatment. We assessed the time-to-adrenalectomy (TTA) for patients worldwide. Methods: We conducted an international, multicentre retrospective study involving 39 centres from 15 countries to determine the total time taken from first presentation to adrenalectomy, and the intervals between each stage (screening, confirmatory, subtyping, adrenalectomy). We included patients with PA who underwent adrenalectomy from 1st January 2018 to 30th October 2022. Post-adrenalectomy outcomes were evaluated using the Primary Aldosteronism Surgery Outcome criteria. We performed multivariable quantile and linear regression to identify characteristics associated with longer TTA. Results: We included 861 patients, mean age 49.3±11.1 years, and 44.5% were women. Overall median TTA was 13.5 months, IQR: 6.6-24.5. Median intervals were 0.1 months (screening), 1.0 months (confirmatory), 4.1 months (subtyping), and 4.3 months (adrenalectomy). On multivariable analysis, median TTA was increased by 5.4 months for each additional adrenal vein sampling (AVS) procedure. Other factors associated with longer TTA included adrenalectomy post COVID-19, younger age, and additional screening tests. Compared to countries with routine AVS, those without AVS had a shorter TTA (6.1 vs. 15.1 months, P<0.001), but greater likelihood of absent/partial biochemical success post-adrenalectomy (27.4% vs. 12.4%, P<0.001). Conclusion: PA management is time-consuming worldwide, especially for subtyping tests and adrenalectomy. While omitting AVS reduces overall time, patients are less likely to achieve biochemical cure post-adrenalectomy.