Josh Leisring

2/ PA is hard to rule out based on a single negative screen. This is why suppressed renin regardless of plasma aldo is notable. And why, despite limitations of confirmatory suppression testing, I still like the 24 hour urine aldo test to ‘rule in’ borderline cases.

1/ Even outside of AVS the intra-individual variability of plasma aldo is important. Another study with the same message. www.ahajournals.org/doi/10.1161/...

This study helped to justify our push for triplicate measurements pre- and post- cosyntropin which was adopted in our new AVS protocol a couple yeas ago!

Chronicles of Chronotherapy in Controlling Cardiovascular Complications — NephJC Dr Hiremath gives the chronotherapy literature a Swap.

That’s exactly our point - the Spanish data made no sense www.nephjc.com/news/chronot...

IMO use long acting meds once a day and timing does not matter

2025 AHA/ACC Guideline for the Prevention, Detection, Evaluation and Management of High Blood Pressure in Adults

08/28/25 @ 12:00 pm – 1:30 pm CDT
Featuring writing committee members and highlights from the
ACC/AHA Committee on Clinical Practice Guidelines
targetbp.org/event/target...

3/3 But until we get something like that I see the early renin/also screen as the pathway to use MRA (and soon ASI) earlier. Identifying PA or at least the low-renin phenotype gives more evidence to stand on.

2/ Would love to see a pragmatic trial (something similar to the diuretic comparison project) to compare MRA to first line agents

1/ Certainly agree that spiro should be used more often. Using it before any of the ‘first-line’ agents (ACE/ARB, thiazide, dCCB) will have detractors given the proven hard-outcome data for those classes. I don’t know that a trial to properly compare 1st-line efficacy of MRA is really feasible.

I share your concerns about implementation by PCPs. Especially if they’re being asked to screen and interpret while on confounding meds. I think we can anticipate more referrals and unnecessary testing for hypereninemia. The case report below has never been more relevant.

bsky.app/profile/josh...

Good points, empiric therapy would probably reach the most patients. On an individual patient level I think it’s worthwhile to do the testing and make the diagnosis to allow targeted management beyond BP (titrate MRA to raise renin for potential non-BP-mediated CV benefits). But it’s hard to scale.

We have a similar outlook at our center.

I agree that confirmatory tests are usually not needed but I do still find 24 hour urine aldo w/ dietary Na load helpful - particularly for ruling in PA in patients with low renin and middling aldo in whom surgery would be considered (exception, not rule).

We screen everyone referred to our hypertension program for many years now

We don’t refer anyone to endo

Most patients just need Spiro

The occasional peeps need AVS and few need an adrenalectomy

Confirmatory tests are useless

Indeed

I suspect these guidelines are trying to shift the Overton window (did I use the phrase correctly 😎 @jordybc.bsky.social ?) - I don’t think PCPs read the JCEM!

Right now even referral centres nephrologists, endocrinologists, cardiologists are doing a shitty job of screening 🤷🏽‍♂️

Agree that the most spironolactone-responsive cases of RHTN are on that spectrum of PA. I have used a similar approach and this practice, along with monitoring for an increase in renin, has been adapted in the new Endo society guideline.

New Primary Aldosteronism Guidelines - simpler, streamlined, and hopefully more pragmatic
academic.oup.com/jcem/advance...

Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline AbstractBackground. Primary aldosteronism (PA), a primary adrenal disorder leading to excessive aldosterone production by one or both adrenal glands, is a

New PA Endo guideline is also out by experts @anandvaidya17.bsky.social #Cardiosky @hswapnil.medsky.social doi.org/10.1210/clin...

Our latest clinical practice guideline, Primary Aldosteronism (bit.ly/44MbrSv), is now available. The new guideline recommends more widespread screening for a common hormonal cause of high blood pressure known as primary aldosteronism. Read in @endocrinenews.bsky.social: bit.ly/4kFadhv #ENDO2025

A figure showing the changes from baseline in systolic blood pressure (SBP), plasma aldosterone–renin ratio (ARR), and serum potassium level for each patient.

In 15 patients with primary aldosteronism, baxdrostat (a second-generation, nonimidazole aldosterone synthase inhibitor) resolved or reduced the severity of hypertension, excessive aldosterone production, and hypokalemia. Full SPARK study results: nej.md/40Js1kz

#ENDO2025

Our new data on subclinical PA and MACE is out in Circulation! For the first time, we show that renin-independant aldosterone production is associated with an increased risk of MACE independently of BP, in people mostly normotensive with low CV risk.
www.ahajournals.org/doi/full/10....

PRESS RELEASE: Mineralys Therapeutics Announces Journal of the American Medical Association (JAMA) Publication of Pivotal Phase 3 Launch-HTN Trial for Lorundrostat

Detailed results from the pivotal P3 Launch-HTN trial were published today in @jama.com, reinforcing lorundrostat’s efficacy in a real-world setting.

Read our press release to learn more: ir.mineralystx.com/news-events/...

#BloodPressure #Cardiology #Cardiosky #MLYS

#WeekendReads

blast from the past archives of #EditorsChoice

🔗 academic.oup.com/ajh/article/...

Could renin guided therapy be cost effective? From 2013, but still very relevant?

An illustration of the REDUCE-AMI trial results

How much do beta blockers help after a heart attack — even when the heart’s pumping well? The latest episode of Beyond Journal Club from @coreimpodcast.bsky.social & NEJM Group explores the REDUCE-AMI trial, which questions whether beta blockers are still needed for all. Listen now: nej.md/4ekdlxX

Should adrenalectomy still be first-line treatment of unilateral PA?
▶️adrenalectomy associates with greater decrease in LVM despite similar BP
▶️shorter duration of HTN associates with greater benefit after surgery
▶️high 24hr urine Na negatively impacts benefit of MRA
tiny.cc/jf2o001 🔒
#nephsky

#ThrowbackThursday

From the highly cited collection, so #free to read!

🔗 academic.oup.com/ajh/article/... 🔓

Urinary Albumin-to-Creatinine Ratio, Serum Potassium Level, Estimated Glomerular Filtration Rate, and Systolic Blood Pressure over Time.

The first #ERA25 simultaneous pub

CONFIDENCE trial of empagliflozin + finerenone in N = 579

Greater reduction in ACR and BP
Note the impressive GFR dip

www.nejm.org/doi/full/10....

3/ I was interested to learn about the modulatory effect that spiro has on CTD-related sympathetic activation and insulin resistance. Maybe there is some specific benefit in adding MRA to thiazide. Just not sure if it’s directly related to blocking aldosterone. (Figure from the referenced study.)

2/ Is secondary (renin-angiotensin-dependent) hyperaldosteronism occurring secondary to diuretics / sodium depletion analogous to physiologic hyperaldosteronism seen with very low Na diet? I don't know.

1/ Interesting read. The conclusion to use MRAs (or maybe ASIs) sooner makes sense to me. But is the main benefit just due to the high prevalence of primary aldosteronism, rather than in offsetting the secondary aldosteronism that accompanies thiazides? #nephsky #cardiosky #endosky #medsky

Counteracting Angiotensinogen Small-Interfering RNA-Mediated Antihypertensive Effects With REVERSIR | Hypertension BACKGROUND: Small-interfering RNA (siRNA) targeting hepatic AGT (angiotensinogen) mRNA depletes AGT, lowering blood pressure for up to 6 months. However, certain situations may require a rapid angiote...

Also glad they came up with an antidote! Hoping to see it tested for safety in humans

www.ahajournals.org/doi/10.1161/...

(personally, I wouldn’t feel comfortable prescribing this without a way to reverse it, e.g., for sepsis or pregnancy)

Looking forward to the next phase 2 trial results for a deeper dive into how this fares in higher risk patients, which I’m guessing is holding up the plans for a larger phase 3 trial

clinicaltrials.gov/study/NCT062...

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