Jes Pa Avs Bypass Bilateral

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name: jes-pa-avs-bypass-bilateral
description: Identifies patients with normokalemia and no adrenal tumors on CT who likely have bilateral PA and may proceed directly to medical therapy without AVS. Triggers include when a clinician notes normokalemia and clean adrenal CT and asks 'Is AVS necessary if I suspect bilateral disease?'
---

# Determine when AVS can be bypassed for suspected bilateral PA

## STEP 1 — Gather Information
Collect serum potassium to confirm normokalemia, perform adrenal CT to assess for tumors, and record sex, age, body mass index (BMI), plasma aldosterone concentration (PAC), aldosterone-to-renin ratio (ARR), and any confirmatory test results.

## STEP 2 — Rule In / Rule Out
If serum potassium is normal (normokalemia) and adrenal CT shows no adrenal tumors, proceed to classify as likely bilateral PA; otherwise, consider AVS for subtype differentiation.

## STEP 3 — Classify or Stratify
Assess likelihood of bilateral PA using additional clinical features: older age, female sex, higher BMI, lower PAC, lower ARR, and confirmatory test results favoring bilateral disease; classify as suspected bilateral PA when these features support bilateral etiology.

## STEP 4 — Decide
Recommend initiating medical therapy with a mineralocorticoid receptor antagonist (MRA) and bypass adrenal venous sampling (AVS) after obtaining sufficient informed consent.

## Clinical Guardrails / Mimics / Pitfalls
Do not bypass AVS in patients with hypokalemia, adrenal tumors on CT, or unilateral PA predictors (e.g., young age, unilateral tumor, high PAC); do not omit informed consent; do not rely solely on normokalemia and normal CT without considering other clinical features; do not proceed to surgery without AVS when bilateral PA is uncertain.

## Concrete Clinical Example
A 58‑year‑old woman with hypertension, serum potassium 4.2 mmol/L, adrenal CT showing no masses, PAC 15 pg/mL, ARR 250, and a positive saline infusion test is classified as likely bilateral PA; she starts spironolactone 50 mg daily and AVS is omitted after discussing risks and benefits.

**Source:** Japan Endocrine Society clinical practice guideline for the diagnosis and management of primary aldosteronism 2021, Japan Endocrine Society, 2021