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Comment by vjk800 | Hacker News Reader

Can someone who knows more about the field to comment on whether this is as revolutionary as it sounds?

Radiologist.

It’s cool, it’s a nice study. The article definitely over hypes the “common cause of hypertension”. These lesions are rare. Most people with high blood pressure have it because of metabolic disease/chronic stress/lifestyle, and it can be managed with changes to diet exercise and meds.

It is true that doing adrenal vein sampling is hard and not always successful. Having a protocol that can non-invasively detect these lesions may save some people a procedure.

Thanks for this. Metabolic/stress/lifestyle problems were exactly my story. I had hypertension, anxiety, and was prediabetic. Using low carb and intermittent fasting, I lost 91 pounds, was no longer prediabetic, and went completely off bp meds. Anxiety is managed much better (no meds). My doc was amazed.

> Most people with high blood pressure have it because of metabolic disease/chronic stress/lifestyle, and it can be managed with changes to diet exercise and meds.

Do we know this though? If, as the article claims, the lesions were previously hard to detect, I would guess that most people with them never get diagnosed. I have high blood pressure and I've never been examined for those lesions.

Yeah there are other ways to tell if someone has aldosterone driven hypertension through blood work and urine tests. These other tests are to determine if surgery could fix the problem (tumor or unilateral vs bilateral abnormal aldosterone production).

Edited for clarity

- this only concerns 5 - 10% of all hypertension patients

- ~50% of adult Americans have hypertension

- scanning all medication-non-responders (= people suffering from "resistant hypertension") and operating on all of them to remove the causative nodules sounds like quite the tall order

- doctors won't just suddenly start sending all the resistant hypertension patients to CTs to diagnose this cause, instead they will continue to escalate their patients anti-hypertensive medication, i.e. adding an aldosterone antagonist to the three other maximum dosage blood pressure lowering medications the patient already takes.

- this might become an option for people suffering from resistant hypertension that are receiving expensive, excellent state of the art treatment

isn't a single CT scan and surgery cheaper than 40 years of medication?

The article/headline is confusing; the real comparison is between a non-invasive PET-CT scan using metomidate as an imaging medium, and invasive and specialized adrenal vein sampling (AVS), both as diagnostic tools.

AVS is correlated using a non-metomidate adrenal CT scan anyway, so a CT-only option would be less expensive and could be performed in more facilities, making it more accessible:

> Until now, 99% are never diagnosed because of the difficulty and unavailability of tests.

And since AVS has such a low predictive success rate (63% per the study), the CT-scan-only alternative doesn't even have to be good, it just has to be about as bad as AVS.

The results of either could very well be "keep taking meds for 40 years" or "surgery helps immensely", but the real cost savings are in avoiding AVS and also potentially diagnosing and treating more people sooner.

(Also mind that the study's done in the UK, where CT scans cost patients about £800/US$1,000 even when done privately, and in Scotland/Wales/N. Ireland the meds are free to the patient. In the US, a CT scan averages about $5,000, $12,000 isn't unheard of, and the meds cost $7,000-$20,000 for 40 years.)

That small question is so complex, it could probably be elucidated in a complete high quality bachelor thesis.

Many of those patients will continue to have high blood pressure for other reasons (obesity, fat intake, renal impairment, god knows what else) and will need to continue their medication, maybe they will downgrade (upgrade? (-; ) from treatment resistant hypertension to normal hypertension. A significant amount of the patients receiving surgery will suffer from mild to severe bacterial infections that also need treatment.

At the top of my head I would still say yes, it would be cheaper.

ALSO and BUT: Please do not expect a treatment that is both cheaper and better for the quality of life of the patient to be chosen by default. Hospitals and doctors don't work that way.

Probably not. The sticker price of my blood pressure medicine comes out to like $60/yr. The scan alone would probably cost more than 40 years of medication (and the #s are potentially much worse if you consider time value of money and all that)

Cost to you, or combined cost for you / insurer ? Honest question.

If I went to Costco and paid cash without invoking my insurance it would be $16 for a 90 day supply (so actually closer to $65/year, oops).

When I go through my insurance with their preferred pharmacy, I don't pay anything. But according to CVS my insurance company pays $1.87 for 90 pills, so about $7/year

Most blood pressure medication is dirt cheap, effective pills have been generic for decades now -- you can get a 3-month supply of the largest dose of lisinopril for under $10 cash (no insurance).

https://costplusdrugs.com/medications/lisinopril-2_5mg-table...

It depends on the type. ARB's are fairly cheap. Alpha 2 receptor agonists are a bit more. When I was on those I paid cash and almost always received a coupon on the spot for some reason but my total price out of pocket was $28 for the agonist and about $12 for the ARB. Some people are on more then 2 types. Happy to be off those things.

It really depends on the surgery. Heart surgery isn't exactly minor and doctors do tend to prefer non-invasive treatment.

I like to minimize on my needed medications though. I would probably opt for this if it were available.

Isn't the described remedial procedure to take a radioactive substance that will burn out the nodules ?) That's not that expensive or invasive.

I understand something similar is done for Morbus Basedow / Grave's disease with the thyroid gland.

The linked article references "surgically curable primary aldosteronism".

You are probably referencing "radioiodine therapy" which is highly specific to thyroid issues.

My bad, I was misreading. They use the radioactive stuff just like a contrast fluid.

That sounds terrible. Are you advocating for that or just saying that is just what will happen.

Saying it will happen. Ideally everyone with treatment resistant blood pressure should now get the CT scan. But this would require a great deal of awareness, training and trust for the blood pressure treating MD/GP, the radiologist and the potential surgeon. Then there is the insurance aspect: Does the insurance in question even allow for this kind of CT scan & urine test for high blood pressure?

Integrating new techniques like this into commonly available treatment is HARD.

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