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Wang WT, Wu TH, Er LK, Huang CW, Tu KH, Fan KC, Tsai CH, Wang SY, Wu CY, Huang SH, Liu HW, Tseng FY, Wu WC, Chang CC, Cheng HM, Lin LY, Chueh JS, Lin YH, Hwu CM, Wu VC. Recent progress in unraveling cardiovascular complications associated with primary aldosteronism: a succinct review. Hypertens Res 2024; 47:1103-1119. [PMID: 38228750 DOI: 10.1038/s41440-023-01538-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 01/18/2024]
Abstract
This comprehensive review offers a thorough exploration of recent advancements in our understanding of the intricate cardiovascular complications associated with Primary Aldosteronism (PA). PA encompasses a spectrum of conditions characterized by hypertension and excessive production of aldosterone operating independently of the renin-angiotensin system. Given its association with an elevated risk of cardiovascular and cerebrovascular complications, as well as a higher incidence of metabolic syndrome in comparison to individuals with essential hypertension (EH), an accurate diagnosis of PA is of paramount importance. This review delves into the intricate interplay between PA and cardiovascular health and focuses on the key pathophysiological mechanisms contributing to adverse cardiac outcomes. The impact of different treatment modalities on cardiovascular health is also examined, offering insights into potential therapeutic approaches. By highlighting the significance of recognizing PA as a significant contributor to cardiovascular morbidity, this review emphasizes the need for improved screening, early diagnosis, and tailored management strategies to both enhance patient care and mitigate the burden of cardiovascular diseases. The findings presented herein underscore the growing importance of PA in the context of cardiovascular medicine and emphasize the potential for translating these insights into targeted interventions to improve patient outcomes.
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Affiliation(s)
- Wei-Ting Wang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
| | - Tsung-Hui Wu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Leay-Kiaw Er
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, The Buddhist Medical Foundation, Hualien, Taiwan, ROC
- School of Medicine, Tzu-Chi University College of Medicine, Hualien, Taiwan, ROC
| | - Chien-Wei Huang
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Nephrology, Department of Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan, ROC
| | - Kun-Hua Tu
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu, Taiwan, ROC
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan, ROC
| | - Cheng-Hsuan Tsai
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Shu-Yi Wang
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan, ROC
| | - Chun-Yi Wu
- Division of Nephrology, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan, ROC
| | - Shu-Heng Huang
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Kaohsiung Medical University Chung-Ho Memorial Hospital, Kaohsiung, Taiwan, ROC
| | - Han-Wen Liu
- Division of Endocrinology & Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan, ROC
| | - Fen-Yu Tseng
- Division of Endocrinology & Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Wan-Chen Wu
- Division of Endocrinology & Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, ROC
- Department and Graduate Institute of Forensic Medicine, National Taiwan University College of Medicine, Taipei, Taiwan, ROC
| | - Hao-Min Cheng
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
| | - Liang-Yu Lin
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Jeff S Chueh
- Primary Aldosteronism Center, National Taiwan University Hospital, (NTUH-PAC), Taipei, Taiwan, ROC
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taipei, Taiwan, ROC
- Department of Urology, National Taiwan University Hospital, Taipei, Taiwan, ROC
| | - Yen-Hung Lin
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan, ROC
- Primary Aldosteronism Center, National Taiwan University Hospital, (NTUH-PAC), Taipei, Taiwan, ROC
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taipei, Taiwan, ROC
| | - Chii-Min Hwu
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan, ROC.
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
| | - Vin-Cent Wu
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan, ROC.
- School of Medicine, Tzu-Chi University College of Medicine, Hualien, Taiwan, ROC.
- Primary Aldosteronism Center, National Taiwan University Hospital, (NTUH-PAC), Taipei, Taiwan, ROC.
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taipei, Taiwan, ROC.
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, ROC.
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Zhou S, Liu J, Li Z, Yang M, Sha R, Yan R, Wang X, Cao Y. The effect of different treatment strategies on glycolipid metabolism disorders and cardiovascular events in primary aldosteronism. Hypertens Res 2024:10.1038/s41440-024-01648-0. [PMID: 38565699 DOI: 10.1038/s41440-024-01648-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/26/2024] [Accepted: 03/01/2024] [Indexed: 04/04/2024]
Abstract
Recent studies have explored the association between primary aldosteronism and cardiovascular disease incidence. The association between specific primary aldosteronism treatments and differential improvement in cardiovascular event rates is yet to be established. This study was designed to compare the relative effects of spironolactone therapy and surgical intervention on cardiovascular outcomes among primary aldosteronism patients. This retrospective observational study included 853 primary aldosteronism patients from the First Affiliated Hospital of China Medical University between 2014 and 2022. Patients who had completed abdominal computed tomography (CT) examinations with similar metabolic characteristics and 6-month follow-up analyses were included in this study. These patients were separated into a surgical treatment group (n = 33) and a spironolactone treatment group (n = 51). Demographic data, biochemical analysis results, liver/spleen (L/S) X-ray attenuation ratio, hospitalization frequency, and cardiovascular events were compared between the two groups. The spironolactone group demonstrated significantly improved metabolic characteristics compared to the surgical group, shown by lower BMI, blood pressure, total cholesterol (TC), insulin resistance index (IRI), and reduced non-alcoholic fatty liver disease prevalence. Metabolic parameters did not differ significantly within the surgical treatment group when comparing pre- and postoperative values. The incidence of cardiovascular events was lower in the spironolactone group compared to the surgery group (23/33 vs. 20/51, P < 0.001) despite higher hospitalization rates(37/31 vs. 61/53, P < 0.001). In patients with primary aldosteronism, spironolactone treatment is more effective than surgical intervention in remediating abnormal lipid and glucose metabolism while improving cardiovascular outcomes. Chinese clinical trial registry registration number: ChiCTR2300074574.
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Affiliation(s)
- Shiting Zhou
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Jing Liu
- Department of Radiology, The First Affiliated Hospital of China Medical University, 110001, Shenyang, China
| | - Zhuo Li
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Mingfeng Yang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Ruohe Sha
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Ruike Yan
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Xinxin Wang
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China
| | - Yanli Cao
- Department of Endocrinology and Metabolism, Institute of Endocrinology, NHC Key Laboratory of Diagnosis and Treatment of Thyroid Diseases, The First Affiliated Hospital of China Medical University, Shenyang, PR China.
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Araujo-Castro M, Ruiz-Sánchez JG, Parra Ramírez P, Martín Rojas-Marcos P, Aguilera-Saborido A, Gómez Cerezo JF, López Lazareno N, Torregrosa Quesada ME, Gorrin Ramos J, Oriola J, Poch E, Oliveras A, Méndez Monter JV, Gómez Muriel I, Bella-Cueto MR, Mercader Cidoncha E, Runkle I, Hanzu FA. Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism. Endocrine 2024:10.1007/s12020-024-03751-1. [PMID: 38448679 DOI: 10.1007/s12020-024-03751-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 02/15/2024] [Indexed: 03/08/2024]
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension (HT), and is associated with a higher cardiometabolic risk than essential HT. However, PA remains underdiagnosed, probably due to several difficulties clinicians usually find in performing its diagnosis and subtype classification. The aim of this consensus is to provide practical recommendations focused on the prevalence and the diagnosis of PA and the clinical implications of aldosterone excess, from a multidisciplinary perspective, in a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), Spanish Society of Cardiology (SEC), Spanish Society of Nephrology (SEN), Spanish Society of Internal Medicine (SEMI), Spanish Radiology Society (SERAM), Spanish Society of Vascular and Interventional Radiology (SERVEI), Spanish Society of Laboratory Medicine (SEQC(ML)), Spanish Society of Anatomic-Pathology, Spanish Association of Surgeons (AEC).
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal. Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS)., Madrid, Spain.
| | - Jorge Gabriel Ruiz-Sánchez
- Endocrinology & Nutrition Department. Hospital Universitario Fundación Jiménez Díaz, Health Research Institute-Fundación Jiménez Díaz University Hospital (IIS-FJD, UAM), Madrid, Spain
| | - Paola Parra Ramírez
- Endocrinology & Nutrition Department, Hospital Universitario La Paz-IdiPAZ, Madrid, Spain
| | | | | | | | - Nieves López Lazareno
- Biochemical Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | | | - Jorge Gorrin Ramos
- Biochemical department, Laboratori de Referència de Catalunya, Barcelona, Spain
| | - Josep Oriola
- Biochemistry and Molecular Genetics Department, CDB. Hospital Clínic. University of Barcelona, Barcelona, Spain
| | - Esteban Poch
- Nephrology Department. Hospital Clinic, IDIBAPS. University of Barcelona, Barcelona, Spain
| | - Anna Oliveras
- Nephrology Department. Hospital del Mar, Universitat Pompeu Fabra, Barcelona, ES, Spain
| | | | | | - María Rosa Bella-Cueto
- Pathology Department, Parc Taulí Hospital Universitari. Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA). Universitat Autònoma de Barcelona. Sabadell, Barcelona, Spain
| | - Enrique Mercader Cidoncha
- General Surgery, Hospital General Universitario Gregorio Marañón, Madrid, Spain
- Fellow European Board of Surgery -Endocrine Surgery, Madrid, Spain
| | - Isabelle Runkle
- Endocrinology and Nutrition Department, Hospital Clínico San Carlos, Madrid, Spain
| | - Felicia A Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic. IDIBAPS. University of Barcelona, Barcelona, Spain.
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Chen ZW, Liao CW, Pan CT, Tsai CH, Chang YY, Chang CC, Lee BC, Chiu YW, Huang WC, Lai TS, Lu CC, Chueh JS, Wu VC, Hung CS, Lin YH. Reversal of arterial stiffness in medically and surgically treated unilateral primary aldosteronism. J Hypertens 2024; 42:538-545. [PMID: 38088428 DOI: 10.1097/hjh.0000000000003631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Hyperaldosteronism has adverse effects on cardiovascular structure and function. Laparoscopic adrenalectomy is the gold standard for patients with unilateral primary aldosteronism. For unilateral primary aldosteronism patients unable or unwilling to undergo surgery, the effects of mineralocorticoid receptor antagonists (MRAs) on the reversibility of arterial stiffness and other clinical data remain unclear. We aimed to compare the reversibility of arterial stiffness using pulse wave velocity (PWV) and other clinical parameters between surgically and medically treated unilateral primary aldosteronism patients. METHODS We prospectively enrolled 306 unilateral primary aldosteronism patients, of whom 247 received adrenalectomy and 59 received medical treatment with MRAs. Detailed medical history, basic biochemistry and PWV data were collected in both groups before treatment and 1 year after treatment. After propensity score matching (PSM) for age, sex, SBP and DBPs, 149 patients receiving adrenalectomy and 54 patients receiving MRAs were included for further analysis. RESULTS After PSM, the patients receiving adrenalectomy had a greater reduction in blood pressure, increase in serum potassium, and change in PWV (ΔPWV, -53 ± 113 vs. -10 ± 140 cm/s, P = 0.028) than those receiving MRAs 1 year after treatment. Multivariable regression analysis further identified that surgery (compared with MRA treatment), baseline PWV, baseline DBP, the change in DBP and the use of diuretics were independently correlated with ΔPWV. CONCLUSION Adrenalectomy is superior to MRA treatment with regards to vascular remodeling when treating unilateral primary aldosteronism patients.
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Affiliation(s)
- Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
| | - Che-Wei Liao
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Medicine, National Taiwan University Cancer Center, Taipei
| | - Chien-Ting Pan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin
| | - Cheng-Hsuan Tsai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University
| | - Yi-Yao Chang
- Department of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City
- Graduate Institute of Medicine, Yuan Ze University, Taoyuan City
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Yu-Wei Chiu
- Department of Cardiovascular Medicine, Far Eastern Memorial Hospital, New Taipei City
- Department of Computer Science and Engineering, Yuan Ze University, Taoyuan City
| | - Wei-Chieh Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital
| | - Tai-Shuan Lai
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Ching-Chu Lu
- Department of Nuclear Medicine, National Taiwan University Hospital
| | - Jeff S Chueh
- Department of Urology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Chi-Sheng Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei
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Samnani S, Cenzer I, Kline GA, Lee SJ, Hundemer GL, McClurg C, Pasieka JL, Boscardin WJ, Ronksley PE, Leung AA. Time to Benefit of Surgery vs Targeted Medical Therapy for Patients With Primary Aldosteronism: A Meta-analysis. J Clin Endocrinol Metab 2024; 109:e1280-e1289. [PMID: 37946600 PMCID: PMC10876395 DOI: 10.1210/clinem/dgad654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 10/20/2023] [Accepted: 11/06/2023] [Indexed: 11/12/2023]
Abstract
CONTEXT Primary aldosteronism (PA) is one of the most common causes of secondary hypertension, but the comparative outcomes of targeted treatment remain unclear. OBJECTIVE To compare the clinical outcomes in patients treated for primary aldosteronism over time. METHODS Medline and EMBASE were searched. Original studies reporting the incidence of mortality, major adverse cardiovascular outcomes (MACE), progression to chronic kidney disease, or diabetes following adrenalectomy vs medical therapy were selected. Two reviewers independently abstracted data and assessed study quality. Standard meta-analyses were conducted using random-effects models to estimate relative differences. Time to benefit meta-analyses were conducted by fitting Weibull survival curves to estimate absolute risk differences and pooled using random-effects models. RESULTS 15 541 patients (16 studies) with PA were included. Surgery was consistently associated with an overall lower risk of death (hazard ratio [HR] 0.34, 95% CI 0.22-0.54) and MACE (HR 0.55, 95% CI 0.36-0.84) compared with medical therapy. Surgery was associated with a significantly lower risk of hospitalization for heart failure (HR 0.48 95% CI 0.34-0.70) and progression to chronic kidney disease (HR 0.62 95% CI 0.39-0.98), and nonsignificant reductions in myocardial infarction and stroke. In absolute terms, 200 patients would need to be treated with surgery instead of medical therapy to prevent 1 death after 12.3 (95% CI 3.1-48.7) months. CONCLUSION Surgery is associated with lower all-cause mortality and MACE than medical therapy for PA. For most patients, the long-term surgical benefits outweigh the short-term perioperative risks.
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Affiliation(s)
- Sunil Samnani
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
| | - Irena Cenzer
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Geriatrics, Palliative and Extended Care Service Line, SanFrancisco VA (Veterans Affairs) Health Care System, San Francisco, CA 94121, USA
| | - Gregory A Kline
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
| | - Sei J Lee
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Geriatrics, Palliative and Extended Care Service Line, SanFrancisco VA (Veterans Affairs) Health Care System, San Francisco, CA 94121, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON K1H 7W9, Canada
| | - Caitlin McClurg
- Library and Cultural Resources, University of Calgary, Calgary, AB T2N 4N1, Canada
| | - Janice L Pasieka
- Departments of Surgery and Oncology, University of Calgary, Calgary, AB T2N 2T9, Canada
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California (SanFrancisco), San Francisco, CA 94121, USA
- Department of Epidemiology and Biostatistics, University of California (SanFrancisco), San Francisco, CA 94158, USA
| | - Paul E Ronksley
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
| | - Alexander A Leung
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB T2T 5C7, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 4Z6, Canada
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Yokota K. Adrenal arterial embolization: a possible new treatment for patients with primary aldosteronism. Hypertens Res 2024; 47:358-360. [PMID: 37828135 DOI: 10.1038/s41440-023-01456-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/13/2023] [Indexed: 10/14/2023]
Affiliation(s)
- Kenichi Yokota
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.
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Charoensri S, Bashaw L, Dehmlow C, Ellies T, Wyckoff J, Turcu AF. Evaluation of a Best-Practice Advisory for Primary Aldosteronism Screening. JAMA Intern Med 2024; 184:174-182. [PMID: 38190155 PMCID: PMC10775078 DOI: 10.1001/jamainternmed.2023.7389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 11/10/2023] [Indexed: 01/09/2024]
Abstract
Importance Primary aldosteronism (PA) is a common cause of secondary hypertension and an independent risk factor for cardiovascular morbidity and mortality. Fewer than 2% to 4% of patients at risk are evaluated for PA. Objective To develop and evaluate an electronic health record best-practice advisory (BPA) that assists with PA screening. Design, Setting, and Participants This prospective quality improvement study was conducted at academic center outpatient clinics. Data analysis was performed between February and June 2023 and included adults with hypertension and at least 1 of the following: 4 or more current antihypertensive medications; hypokalemia; age younger than 35 years; or adrenal nodule(s). Patients previously tested for PA were excluded. Exposure A noninterruptive BPA was developed to trigger for PA screening candidates seen in outpatient setting by clinicians who treat hypertension. The BPA included an order set for PA screening and a link to results interpretation guidance. Main Outcomes and Measures (1) The number of PA screening candidates identified by the BPA between October 1, 2021, and December 31, 2022; (2) the rates of PA screening; and (3) the BPA use patterns, stratified by physician specialty were assessed. Results Over 15 months, the BPA identified 14 603 unique candidates (mean [SD] age, 65.5 [16.9] years; 7300 women [49.9%]; 371 [2.5%] Asian, 2383 [16.3%] Black, and 11 225 [76.9%] White individuals) for PA screening, including 7028 (48.1%) with treatment-resistant hypertension, 6351 (43.5%) with hypokalemia, 1537 (10.5%) younger than 35 years, and 445 (3.1%) with adrenal nodule(s). In total, 2040 patients (14.0%) received orders for PA screening. Of these, 1439 patients (70.5%) completed the recommended screening within the system, and 250 (17.4%) had positive screening results. Most screening orders were placed by internists (40.0%) and family medicine physicians (28.1%). Family practitioners (80.3%) and internists (68.9%) placed most orders via the embedded order set, while specialists placed most orders (83.0%-95.4%) outside the BPA. Patients who received screening were younger and included more women and Black patients than those not screened. The likelihood of screening was higher among patients with obesity and dyslipidemia and lower in those with chronic kidney disease and established cardiovascular complications. Conclusions and Relevance The study results suggest that noninterruptive BPAs are potentially promising PA screening-assistance tools, particularly among primary care physicians. Combined with artificial intelligence algorithms that optimize the detection yield, refined BPAs may contribute to personalized hypertension care.
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Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Linda Bashaw
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Cheryl Dehmlow
- Health Information and Technology Systems, University of Michigan, Ann Arbor
| | - Tammy Ellies
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Jennifer Wyckoff
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor
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8
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Hundemer GL, Leung AA, Kline GA, Brown JM, Turcu AF, Vaidya A. Biomarkers to Guide Medical Therapy in Primary Aldosteronism. Endocr Rev 2024; 45:69-94. [PMID: 37439256 PMCID: PMC10765164 DOI: 10.1210/endrev/bnad024] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 07/11/2023] [Indexed: 07/14/2023]
Abstract
Primary aldosteronism (PA) is an endocrinopathy characterized by dysregulated aldosterone production that occurs despite suppression of renin and angiotensin II, and that is non-suppressible by volume and sodium loading. The effectiveness of surgical adrenalectomy for patients with lateralizing PA is characterized by the attenuation of excess aldosterone production leading to blood pressure reduction, correction of hypokalemia, and increases in renin-biomarkers that collectively indicate a reversal of PA pathophysiology and restoration of normal physiology. Even though the vast majority of patients with PA will ultimately be treated medically rather than surgically, there is a lack of guidance on how to optimize medical therapy and on key metrics of success. Herein, we review the evidence justifying approaches to medical management of PA and biomarkers that reflect endocrine principles of restoring normal physiology. We review the current arsenal of medical therapies, including dietary sodium restriction, steroidal and nonsteroidal mineralocorticoid receptor antagonists, epithelial sodium channel inhibitors, and aldosterone synthase inhibitors. It is crucial that clinicians recognize that multimodal medical treatment for PA can be highly effective at reducing the risk for adverse cardiovascular and kidney outcomes when titrated with intention. The key biomarkers reflective of optimized medical therapy are unsurprisingly similar to the physiologic expectations following surgical adrenalectomy: control of blood pressure with the fewest number of antihypertensive agents, normalization of serum potassium without supplementation, and a rise in renin. Pragmatic approaches to achieve these objectives while mitigating adverse effects are reviewed.
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Affiliation(s)
- Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, ON K1H 8L6, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON K1H 8L6, Canada
| | - Alexander A Leung
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Gregory A Kline
- Department of Medicine, Division of Endocrinology and Metabolism, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI 48109, USA
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Mah D, Kneteman M, Przybojewski SJ, Kotha V, Kline GA, Leung AA, So CB. Multiple radiologist review of adrenal CT still frequently misses lateralized surgical primary aldosteronism. J Clin Hypertens (Greenwich) 2024; 26:47-52. [PMID: 38083996 PMCID: PMC10795078 DOI: 10.1111/jch.14747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 09/23/2023] [Accepted: 10/25/2023] [Indexed: 01/19/2024]
Abstract
Patients with primary aldosteronism (PA) have increased morbidity and mortality compared to those with essential hypertension. Accurate detection of lateralized PA is important so that affected patients can receive potentially curative adrenalectomy. However, around 40% of patients with lateralized PA have "normal" adrenal glands on computed tomography (CT). Additional independent review of imaging has been shown to improve diagnostic accuracy in many areas of imaging. Therefore, the authors sought to establish if multi-reader re-assessment of previously reported normal CT scans would result in increased detection of surgically remediable disease. The authors found that re-assessment of CT imaging by one, two, or three additional radiologists (or a combination thereof) slightly increased the detection of lateralized disease, but these differences were not statistically significant (p > .05). Readers had low inter-observer agreement (kappa = 0.17). If detection of a discrete nodule on CT was made a prerequisite for adrenal vein sampling (AVS), a second read by another reviewer would still result in an excess of missed cases (84.2%, 36.8%, and 65.8%, respectively, for each of the three independent reviewers). Therefore, a "normal" CT does not preclude the possibility of lateralized PA. Adrenal vein sampling should still be strongly considered wherever available and whenever surgery is considered for treatment of PA, irrespective of CT findings.
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Affiliation(s)
- Darren Mah
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
| | - Mark Kneteman
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
| | | | - Vamshi Kotha
- Clinical Assistant ProfessorUniversity of CalgaryCalgaryABCanada
| | - Gregory A. Kline
- Department of MedicineDivision of Endocrinology and MetabolismUniversity of CalgaryCalgaryABCanada
| | - Alexander A. Leung
- Department of MedicineDivision of Endocrinology and MetabolismUniversity of CalgaryCalgaryABCanada
- Department of Community Health SciencesUniversity of CalgaryCalgaryABCanada
| | - C. Benny So
- Department of RadiologyUniversity of CalgaryCalgaryABCanada
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10
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Zuo R, Liu S, Xu L, Pang H. Key to the Treatment of Primary Aldosteronism in Secondary Hypertension: Subtype Diagnosis. Curr Hypertens Rep 2023; 25:471-480. [PMID: 37787864 DOI: 10.1007/s11906-023-01269-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/12/2023] [Indexed: 10/04/2023]
Abstract
PURPOSE OF REVIEW Primary aldosteronism (PA) is a leading global cause of secondary hypertension. Subtyping diagnosis of PA is the key to surgery, but accurate classification of PA is crucial but challenging in clinical diagnosis and treatment. The purpose of this review is to provide a summary of current literature and propose subtyping diagnosis flow chart to help us classify PA quickly and accurately. RECENT FINDINGS Early diagnosis and accurate typing are essential for the timely treatment and appropriate management of PA. For most patients, adrenal venous sampling (AVS) is the central choice for typing diagnosis, but AVS is invasive and difficult to promote effectively. CT can help identify unilateral typical adenomas in select patients to avoid AVS. New radionuclide imaging has shown value in the diagnosis and classification of PA, which distinguishes adrenocortical hyperplasia from adenoma and can replace AVS in some patients. Accurately diagnosing unilateral PA is crucial for determining the appropriate treatment strategy for PA. The simple flow chart of PA subtyping diagnosis based on the current literature needs to be verified and evaluated by follow-up researches.
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Affiliation(s)
- Rui Zuo
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, China
| | - Shuang Liu
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, China
| | - Lu Xu
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, China
| | - Hua Pang
- Department of Nuclear Medicine, The First Affiliated Hospital of Chongqing Medical University, No. 1 Youyi Road, Chongqing, 400016, China.
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11
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Gkaniatsa E, Zverkova Sandström T, Rosengren A, Trimpou P, Olsson DS, Lind M, Muth A, Johannsson G, Ragnarsson O. Mortality in Patients With Primary Aldosteronism: A Swedish Nationwide Study. Hypertension 2023; 80:2601-2610. [PMID: 37855142 DOI: 10.1161/hypertensionaha.123.21895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/10/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Primary aldosteronism (PA) is associated with increased mortality. The extent to which this phenomenon is affected by sex, age, comorbidities at diagnosis, and different treatment modalities is largely unknown. The objective was to determine all-cause and cause-specific mortality in a population-based cohort of patients with PA and the impact of age at diagnosis, sex, comorbidities, and treatment modalities. METHODS We used national registers to identify patients diagnosed with PA between 1997 and 2019 (n=2419) and controls (n=24 187) from the general population, matched for sex, age, and county of residence. We obtained mortality data from the Cause-of-Death Register. We used Cox regression models, adjusted for socioeconomic factors and diabetes, to estimate adjusted hazard ratios (HRs [95% CI]). RESULTS Overall, 346 (14.3%) patients with PA and 2736 (11.3%) controls died during a median follow-up time of 8.1 years. PA was associated with increased risk from all-cause mortality (HR, 1.23 [95% CI, 1.10-1.38]), death from cardiovascular disease (HR, 1.57 [95% CI, 1.30-1.89]), and stroke (HR, 1.85 [95% CI, 1.16-2.93]). Patients with cardiovascular disease at diagnosis (HR, 1.53 [1.26-1.85]), age >56 years (HR, 1.28 [95% CI, 1.13-1.45]), patients treated with a low dose of a mineralocorticoid receptor antagonist (HR, 1.30 [95% CI, 1.02-1.66]), and untreated patients (HR, 2.51 [95% CI, 1.72-3.67]) had excess mortality. CONCLUSIONS Mortality, mainly due to cardiovascular disease, is increased in patients with PA compared with controls from the general population, particularly in patients aged >56 years, patients with preexisting cardiovascular comorbidities, and patients receiving low dose of a mineralocorticoid receptor antagonist.
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Affiliation(s)
- Eleftheria Gkaniatsa
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Annika Rosengren
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine (A.R., M.L.), University of Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Medicine, Geriatrics and Emergency Medicine (A.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Daniel S Olsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
- Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (D.S.O.)
| | - Marcus Lind
- Department of Molecular and Clinical Medicine, Institute of Medicine (A.R., M.L.), University of Gothenburg, Sweden
- Department of Medicine, NU Hospital Group, Uddevalla, Sweden (M.L.)
| | - Andreas Muth
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital (A.M.), University of Gothenburg, Sweden
| | - Gudmundur Johannsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
| | - Oskar Ragnarsson
- Department of Endocrinology (E.G., P.T., D.S.O., G.J., O.R.), Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine (E.G., P.T., D.S.O., G.J., O.R.), University of Gothenburg, Sweden
- Sahlgrenska Academy, Wallenberg Centre for Molecular and Translational Medicine, Institute of Medicine (O.R.), University of Gothenburg, Sweden
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12
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Rossi GP, Bagordo D, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimský J, Naruse M, Deinum J, Kocjan T, Negro A, Rossi E, Kline G, Tanabe A, Satoh F, Rump LC, Vonend O, Willenberg HS, Fuller PJ, Yang J, Chee NYN, Magill SB, Shafigullina Z, Quinkler M, Oliveras A, Lee BC, Chang CC, Wu VC, Krátká Z, Battistel M, Rossitto G, Seccia TM. Unilaterally Selective Adrenal Vein Sampling for Identification of Surgically Curable Primary Aldosteronism. Hypertension 2023; 80:2003-2013. [PMID: 37317838 DOI: 10.1161/hypertensionaha.123.21247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/23/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Adrenal venous sampling is recommended for the identification of unilateral surgically curable primary aldosteronism but is often clinically useless, owing to failed bilateral adrenal vein cannulation. OBJECTIVES To investigate if only unilaterally selective adrenal vein sampling studies can allow the identification of the responsible adrenal. METHODS Among 1625 patients consecutively submitted to adrenal vein sampling in tertiary referral centers, we selected those with selective adrenal vein sampling results in at least one side; we used surgically cured unilateral primary aldosteronism as gold reference. The accuracy of different values of the relative aldosterone secretion index (RASI), which estimates the amount of aldosterone produced in each adrenal gland corrected for catheterization selectivity, was examined. RESULTS We found prominent differences in RASI values distribution between patients with and without unilateral primary aldosteronism. The diagnostic accuracy of RASI values estimated by the area under receiver operating characteristic curves was 0.714 and 0.855, respectively, in the responsible and the contralateral side; RASI values >2.55 and ≤0.96 on the former and the latter side furnished the highest accuracy for detection of surgically cured unilateral primary aldosteronism. Moreover, in the patients without unilateral primary aldosteronism, only 20% and 16% had RASI values ≤0.96 and >2.55. CONCLUSIONS With the strength of a large real-life data set and use of the gold reference entailing an unambiguous diagnosis of unilateral primary aldosteronism, these results indicate the feasibility of identifying unilateral primary aldosteronism using unilaterally selective adrenal vein sampling results. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01234220.
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Affiliation(s)
- Gian Paolo Rossi
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Domenico Bagordo
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
| | - Laurence Amar
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Michel Azizi
- Université Paris Cité, INSERM UMRS 970 and CIC1418, F-75015 Paris, France; AP-HP, Hôpital Européen Georges Pompidou, Hypertension Unit, F-75015 Paris, France (L.A., M.A.)
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Christoph Degenhart
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, Germany (A.R., M.R., C.D.)
| | - Jiří Widimský
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | - Mitsuhide Naruse
- Department of Endocrinology Clinical Research Institute, National Hospital Organization Kyoto Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan (M.N.)
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Medical Center, Nijmegen, The Netherlands (J.D.)
| | - Tomaz Kocjan
- University Medical Centre Ljubljana, Ljubljana, Slovenia; Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia (T.K.)
| | - Aurelio Negro
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Ermanno Rossi
- Internal Medicine and Hypertension Center, Ospedale Sant'Anna di Castelnovo Ne' Monti, Azienda Usl-IRCCS di Reggio Emilia (A.N., E.R.)
| | - Gregory Kline
- Foothills Medical Centre, University of Calgary, Canada (G.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine (A.T.)
| | - Fumitoshi Satoh
- Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Japan (F.S.)
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Oliver Vonend
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism, Rostock University Medical Center, Rostock, Germany (H.S.W.)
| | - Peter J Fuller
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | - Jun Yang
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | | | - Steven B Magill
- Endocrinology Center, North Hills Health Center, Medical College of Wisconsin, Menomonee Falls (S.B.M.)
| | | | | | - Anna Oliveras
- Hypertension Unit, Nephrology Department, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain (A.O.)
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital (B.-C.L., C.-C.C.), Taipei
- National Taiwan University College of Medicine (C.-C.C.), Taipei
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine (V.C.W.), Taipei
| | - Zuzana Krátká
- 3rd Department of Medicine - Department of Endocrinology and Metabolism, 1st Faculty of Medicine and General University Hospital, Prague, Czech Republic (J.W., Z.K.)
| | | | - Giacomo Rossitto
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (G.R.)
| | - Teresa Maria Seccia
- Hypertension Unit, Department of Medicine, DIMED, University Hospital, University of Padova, Italy (G.P.R., D.B., G.R., T.M.S.)
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13
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Laffin LJ, Rodman D, Luther JM, Vaidya A, Weir MR, Rajicic N, Slingsby BT, Nissen SE. Aldosterone Synthase Inhibition With Lorundrostat for Uncontrolled Hypertension: The Target-HTN Randomized Clinical Trial. JAMA 2023; 330:1140-1150. [PMID: 37690061 PMCID: PMC10493865 DOI: 10.1001/jama.2023.16029] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 07/31/2023] [Indexed: 09/12/2023]
Abstract
Importance Excess aldosterone production contributes to hypertension in both classical hyperaldosteronism and obesity-associated hypertension. Therapies that reduce aldosterone synthesis may lower blood pressure. Objective To compare the safety and efficacy of lorundrostat, an aldosterone synthase inhibitor, with placebo, and characterize dose-dependent safety and efficacy to inform dose selection in future trials. Design, Setting, and Participants Randomized, placebo-controlled, dose-ranging trial among adults with uncontrolled hypertension taking 2 or more antihypertensive medications. An initial cohort of 163 participants with suppressed plasma renin (plasma renin activity [PRA] ≤1.0 ng/mL/h) and elevated plasma aldosterone (≥1.0 ng/dL) were enrolled, with subsequent enrollment of 37 participants with PRA greater than 1.0 ng/mL/h. Interventions Participants were randomized to placebo or 1 of 5 dosages of lorundrostat in the initial cohort (12.5 mg, 50 mg, or 100 mg once daily or 12.5 mg or 25 mg twice daily). In the second cohort, participants were randomized in a 1:6 ratio to placebo or lorundrostat, 100 mg once daily. Main Outcomes and Measures The primary end point was change in automated office systolic blood pressure from baseline to study week 8. Results Between July 2021 and June 2022, 200 participants were randomized, with final follow-up in September 2022. Following 8 weeks of treatment in participants with suppressed PRA, changes in office systolic blood pressure of -14.1, -13.2, -6.9, and -4.1 mm Hg were observed with 100 mg, 50 mg, and 12.5 mg once daily of lorundrostat and placebo, respectively. Observed reductions in systolic blood pressure in individuals receiving twice-daily doses of 25 mg and 12.5 mg of lorundrostat were -10.1 and -13.8 mm Hg, respectively. The least-squares mean difference between placebo and treatment in systolic blood pressure was -9.6 mm Hg (90% CI, -15.8 to -3.4 mm Hg; P = .01) for the 50-mg once-daily dose and -7.8 mm Hg (90% CI, -14.1 to -1.5 mm Hg; P = .04) for 100 mg daily. Among participants without suppressed PRA, 100 mg once daily of lorundrostat decreased systolic blood pressure by 11.4 mm Hg (SD, 2.5 mm Hg), which was similar to blood pressure reduction among participants with suppressed PRA receiving the same dose. Six participants had increases in serum potassium above 6.0 mmol/L that corrected with dose reduction or drug discontinuation. No instances of cortisol insufficiency occurred. Conclusions and Relevance Among individuals with uncontrolled hypertension, use of lorundrostat was effective at lowering blood pressure compared with placebo, which will require further confirmatory studies. Trial Registration ClinicalTrials.gov Identifier: NCT05001945.
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Affiliation(s)
- Luke J Laffin
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
| | | | - James M Luther
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anand Vaidya
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Steven E Nissen
- Cleveland Clinic Foundation, Cleveland, Ohio
- C5 Research, Cleveland Clinic Foundation, Cleveland, Ohio
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14
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Umapathysivam MM, Morgan B, Bischoff C, Hayes A, Wilks M, Stowasser M, Torpy DJ. Intraprocedural cortisol testing improves adrenal vein cannulation success and diagnostic accuracy in assessment of primary aldosteronism, in a medium throughput centre. J Hum Hypertens 2023; 37:783-787. [PMID: 36180577 PMCID: PMC10471492 DOI: 10.1038/s41371-022-00756-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 08/26/2022] [Accepted: 09/12/2022] [Indexed: 11/09/2022]
Abstract
Primary aldosteronism is the most common cause of secondary hypertension. Identifying individuals who have unilateral secretion from aldosterone secreting adenomas allows adrenalectomy. Surgical treatment when feasible may be superior to medical management with improved cardiovascular outcomes and reduced medication dependence. Adrenal vein sampling (AVS) is required to biochemically lateralise aldosterone secretion prior to adrenalectomy. However, diagnostic success of AVS is variable and can be poor even at tertiary centres; failure is largely due to unsuccessful adrenal vein cannulation. Intra-procedural rapid semiquantitative cortisol testing (RCT) identifies correct catheter placement in real time. We compared diagnostic success rates of AVS before and after the introduction of intraprocedural cortisol testing at the Royal Adelaide Hospital-a medium throughput tertiary centre (average 6.2 procedures a year over the last 8 years). We observed an increase in success rate from 63% to 94%. Intraprocedural cortisol testing also led to a net financial saving of ~$100 AUD per procedure. RCT is likely to be cost effective if pre-RCT success rate is less than 78%. Procedure time and number of samples collected, however, were increased with RCT. This suggests that intraprocedural cortisol testing will improve success in low to medium throughput centres and may make AVS feasible in less specialised centres.
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Affiliation(s)
- Mahesh M Umapathysivam
- Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia.
- University of Adelaide, Adelaide, SA, Australia.
| | | | - Carmen Bischoff
- Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Annabelle Hayes
- Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | - Michael Wilks
- Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
| | | | - David J Torpy
- Central Adelaide Local Health Network, SA Health, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
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15
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Sakaguchi S, Okamoto R, Inoue C, Akao M, Kamemura K, Kurihara I, Takeda Y, Ohno Y, Inagaki N, Rakugi H, Katabami T, Tsuiki M, Tanabe A, Tamura K, Fujita S, Yano Y, Dohi K, Naruse M. Associated factors and effects of comorbid atrial fibrillation in hypertensive patients due to primary aldosteronism. J Hum Hypertens 2023; 37:757-766. [PMID: 36153382 DOI: 10.1038/s41371-022-00753-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 08/11/2022] [Accepted: 09/02/2022] [Indexed: 11/08/2022]
Abstract
The incidence of atrial fibrillation (AF) and risk of cardiovascular events are reportedly higher in patients with primary aldosteronism (PA) than essential hypertension. However, associated factors of comorbid AF and cardiovascular events in PA patients after PA treatment remain unclear. This nationwide registration study included PA patients ≥20 years old. Incident cardiovascular events were observed with a mean follow-up of approximately 3 years. A total of 3654 patients with PA were included at the time of analysis. Prevalence of AF was 2.4%. PA patients with AF were older, more frequently male and had longer duration of hypertension than those without AF. No significant difference in basal plasma and adrenal venous aldosterone concentration, renin activity, potassium concentration, confirmatory tests of PA, laterality or surgery rate were seen between groups. Logistic regression analysis showed age, male sex, cardiothoracic ratio, past history of coronary artery disease and heart failure were independent factors associated with AF. PA patients with AF showed a higher frequency of cardiovascular events than those without AF (P < 0.001). Multivariate Cox analyses demonstrated AF in addition to older age, duration of hypertension, body mass index and chronic kidney disease as independent prognostic factors for cardiovascular events after PA treatment. Incidence of cardiovascular events were significantly lower in PA patients with AF than AF patients from the Fushimi registry during follow-up after adjusting age, sex and systolic blood pressure. Early diagnosis of PA may prevent AF and other cardiovascular events in PA patients by shortening the duration of hypertension and appropriate PA treatment.
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Affiliation(s)
- Shintaro Sakaguchi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
- Department of Cardiology, Matsusaka Municipal Hospital, Matsusaka, Japan
| | - Ryuji Okamoto
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Chisa Inoue
- Department of Diabetes, Metabolism and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | | | - Isao Kurihara
- Department of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshiyu Takeda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Youichi Ohno
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University, Kyoto, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University, Kyoto, Japan
| | - Hiromi Rakugi
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St. Marianna University School of Medicine Yokohama City Seibu Hospital, Yokohama, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center and Endocrine Center, Kyoto, Japan
| | - Akiyo Tanabe
- Division of Endocrinology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Satoshi Fujita
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yutaka Yano
- Department of Diabetes, Metabolism and Endocrinology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mitsuhide Naruse
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center and Endocrine Center, Kyoto, Japan
- Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
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16
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Funes Hernandez M, Bhalla V. Underdiagnosis of Primary Aldosteronism: A Review of Screening and Detection. Am J Kidney Dis 2023; 82:333-346. [PMID: 36965825 DOI: 10.1053/j.ajkd.2023.01.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 01/08/2023] [Indexed: 03/27/2023]
Abstract
A clinical condition may be missed due to its higher-than-recognized prevalence or inadequate diagnostic screening. Both factors apply to primary aldosteronism, which is woefully underdiagnosed as a cause of hypertension and end-organ damage. Screening tests should be strongly considered for diseases that pose significant morbidity or mortality if left untreated, that have a high prevalence, and that have treatments that lead to improvement or cure. In this review we present the evidence for each of these points. We outline studies that estimate the prevalence of primary aldosteronism in different at-risk populations and how its recognition has changed over time. We also evaluate myriad studies of screening rates for primary aldosteronism and what factors do and do not influence current screening practices. We discuss the ideal conditions for screening, measuring the aldosterone to renin ratio in different populations that use plasma renin activity or direct renin concentration, and the steps for diagnostic workup of primary aldosteronism. Finally, we conclude with potential strategies to implement higher rates of screening and diagnosis of this common, consequential, and treatable disease.
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Affiliation(s)
- Mario Funes Hernandez
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California
| | - Vivek Bhalla
- Stanford Hypertension Center and Division of Nephrology, Department of Medicine, School of Medicine, Stanford University, Stanford, California.
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17
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Beninato T, Duh QY, Long KL, Kiernan CM, Miller BS, Patel S, Randle RW, Wachtel H, Zanocco KA, Zern NK, Drake FT. Challenges and controversies in adrenal surgery: A practical approach. Curr Probl Surg 2023; 60:101374. [PMID: 37770163 DOI: 10.1016/j.cpsurg.2023.101374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Affiliation(s)
- Toni Beninato
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Quan-Yang Duh
- Veterans Affairs Medical Center, San Francisco, San Francisco, CA
| | | | - Colleen M Kiernan
- Vanderbilt University Medical Center, Veterans Affairs Medical Center, Tennessee Valley Health System, Nashville, TN
| | - Barbra S Miller
- Division of Surgical Oncology, The Ohio State University, Columbus, OH
| | - Snehal Patel
- Emory University School of Medicine, Atlanta, GA
| | | | | | - Kyle A Zanocco
- David Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, CA
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18
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Hong N, Kim KJ, Yu MH, Jeong SH, Lee S, Lim JS, Rhee Y. Risk of dementia in primary aldosteronism compared with essential hypertension: a nationwide cohort study. Alzheimers Res Ther 2023; 15:136. [PMID: 37568223 PMCID: PMC10416485 DOI: 10.1186/s13195-023-01274-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 07/12/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND Although hypertension is a critical risk factor for dementia, the association between primary aldosteronism (PA) and dementia has been scarcely reported. We aimed to investigate whether the risk of dementia in patients with PA was elevated compared with patients with essential hypertension (EH). METHODS From the National Health Insurance Claim database in Korea (2003-2017), 3,687 patients with PA (adrenalectomy [ADX], n = 1,339, mineralocorticoid receptor antagonist [MRA] n = 2,348) with no prior dementia were age- and sex-matched at a 1:4 ratio to patients with EH (n = 14,741). The primary outcomes were all-cause dementia events, including Alzheimer's disease, vascular dementia, or other dementia combined with a prescription of one or more medications for dementia (donepezil, galantamine, memantine, or rivastigmine). Multivariable Cox regression models were used to evaluate the hazard ratios (HRs) and 95% confidence intervals for the outcome incidence rates between patients with PA and their EH matches. RESULTS During a median follow-up of 5.2 years, there were 156 cases of all-cause dementia (4.2%), 140 cases of Alzheimer's disease (3.8%), and 65 cases of vascular dementia (1.8%). Compared with EH, the risk of all-cause dementia was increased in treated PA (unadjusted hazard ratio [HR] 1.26; p < 0.011). Among PA, MRA group had higher risks of all-cause dementia, especially vascular dementia, adjusted for age, sex, income, comorbidities, and concurrent medication (adjusted HR 1.31; p = 0.027 and adjusted HR 1.62; p = 0.020, respectively) compared to EH. ADX group seemed to have a lower dementia risk than the EH group, but there was no statistical significance after full adjustment. This trend became more prominent when the dementia risks were evaluated from the time of hypertension diagnosis rather than treatment initiation for PA. CONCLUSION The findings of this cohort study suggest that PA, especially the MRA group, is associated with an increased risk of dementia. Monitoring cognitive function in PA patients even after treatment initiation might be warranted to prevent dementia.
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Affiliation(s)
- Namki Hong
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Kyoung Jin Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
| | - Min Heui Yu
- SENTINEL Team, Division of Endocrinology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seong Ho Jeong
- Department of Neurology, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Seunghyun Lee
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20, Ilsan-Ro, Wonju-Si, Gangwon-Do, 26426, Republic of Korea
| | - Jung Soo Lim
- Department of Internal Medicine, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, 20, Ilsan-Ro, Wonju-Si, Gangwon-Do, 26426, Republic of Korea.
| | - Yumie Rhee
- Department of Internal Medicine, Severance Hospital, Endocrine Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-Ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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19
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Charoensri S, Turcu AF. Primary Aldosteronism Prevalence - An Unfolding Story. Exp Clin Endocrinol Diabetes 2023; 131:394-401. [PMID: 36996879 DOI: 10.1055/a-2066-2696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Primary aldosteronism (PA) is characterized by dysregulated, renin-independent aldosterone excess. Long perceived as rare, PA has emerged as one of the most common causes of secondary hypertension. Failure to recognize and treat PA results in cardiovascular and renal complications, through processes mediated by both direct target tissue insults and indirectly, by hypertension. PA spans a continuum of dysregulated aldosterone secretion, which is typically recognized in late stages after treatment-resistant hypertension and cardiovascular and/or renal complications develop. Determining the precise disease burden remains challenging due to heterogeneity in testing, arbitrary thresholds, and populations studied. This review summarizes the reports on PA prevalence among the general population and in specific high-risk subgroups, highlighting the impact of rigid versus permissive criteria on PA prevalence perception.
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Affiliation(s)
- Suranut Charoensri
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, USA. Ann Arbor, Michigan
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20
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Hiremath S, Hundemer GL. Evidence and Uncertainties Surrounding Renin-Guided Medical Therapy for Primary Aldosteronism. Am J Hypertens 2023; 36:428-430. [PMID: 37061828 PMCID: PMC10345469 DOI: 10.1093/ajh/hpad034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/12/2023] [Indexed: 04/17/2023] Open
Affiliation(s)
- Swapnil Hiremath
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada
| | - Gregory L Hundemer
- Department of Medicine, Division of Nephrology, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada
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21
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Cohen JB, Bancos I, Brown JM, Sarathy H, Turcu AF, Cohen DL. Primary Aldosteronism and the Role of Mineralocorticoid Receptor Antagonists for the Heart and Kidneys. Annu Rev Med 2023; 74:217-230. [PMID: 36375469 PMCID: PMC9892285 DOI: 10.1146/annurev-med-042921-100438] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension but is frequently underrecognized and undertreated. Patients with PA are at a markedly increased risk for target organ damage to the heart and kidneys. While patients with unilateral PA can be treated surgically, many patients with PA are not eligible or willing to undergo surgery. Steroidal mineralocorticoid receptor antagonists (MRAs) are highly effective for treating PA and reducing the risk of target organ damage. However, steroidal MRAs are often underprescribed and can be poorly tolerated by some patients due to side effects. Nonsteroidal MRAs reduce adverse renal and cardiovascular outcomes among patients with diabetic kidney disease and are bettertolerated than steroidal MRAs. While their blood pressure-lowering effects remain unclear, these agents may have a potential role in reducing target organ damage in patients with PA.
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Affiliation(s)
- Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; ,
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Irina Bancos
- Division of Endocrinology, Metabolism and Nutrition, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA;
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
| | - Harini Sarathy
- Division of Nephrology, Department of Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA;
| | - Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA;
| | - Debbie L Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; ,
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22
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Cardiovascular Disease in Obstructive Sleep Apnea: Putative Contributions of Mineralocorticoid Receptors. Int J Mol Sci 2023; 24:ijms24032245. [PMID: 36768567 PMCID: PMC9916750 DOI: 10.3390/ijms24032245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a chronic and highly prevalent condition that is associated with oxidative stress, inflammation, and fibrosis, leading to endothelial dysfunction, arterial stiffness, and vascular insulin resistance, resulting in increased cardiovascular disease and overall mortality rates. To date, OSA remains vastly underdiagnosed and undertreated, with conventional treatments yielding relatively discouraging results for improving cardiovascular outcomes in OSA patients. As such, a better mechanistic understanding of OSA-associated cardiovascular disease (CVD) and the development of novel adjuvant therapeutic targets are critically needed. It is well-established that inappropriate mineralocorticoid receptor (MR) activation in cardiovascular tissues plays a causal role in a multitude of CVD states. Clinical studies and experimental models of OSA lead to increased secretion of the MR ligand aldosterone and excessive MR activation. Furthermore, MR activation has been associated with worsened OSA prognosis. Despite these documented relationships, there have been no studies exploring the causal involvement of MR signaling in OSA-associated CVD. Further, scarce clinical studies have exclusively assessed the beneficial role of MR antagonists for the treatment of systemic hypertension commonly associated with OSA. Here, we provide a comprehensive overview of overlapping mechanistic pathways recruited in the context of MR activation- and OSA-induced CVD and propose MR-targeted therapy as a potential avenue to abrogate the deleterious cardiovascular consequences of OSA.
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23
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Antihypertensive Effects of Esaxerenone in Older Patients with Primary Aldosteronism. Int J Hypertens 2023; 2023:6453933. [PMID: 36704237 PMCID: PMC9873463 DOI: 10.1155/2023/6453933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 12/03/2022] [Accepted: 12/20/2022] [Indexed: 01/18/2023] Open
Abstract
Design Retrospective cohort study. Patients. The data was obtained from a total of 87 PA patients treated with esaxerenone. The treatment group comprised 33 patients who received esaxerenone as first-line therapy and 54 patients that switched from another MRA to esaxerenone. Measurements. Blood pressure (BP), plasma aldosterone concentration (PAC), plasma renin activity (PRA), serum potassium level, estimated glomerular filtration rate (eGFR), urinary albumin-creatinine ratio (UACR), and brain natriuretic peptide (BNP) were assessed before and after treatment with esaxerenone. Patients with overall reductions in their systolic or diastolic BP by 10 mmHg, or more, were considered responders. Unpaired t-tests of the biochemical and personal parameters between responders and nonresponders were run to find the most influencing characteristic for treatment success. Results BP overall decreased after treatment with esaxerenone (systolic BP: P=0.025, diastolic BP: P=0.096). Serum potassium levels increased, while eGFR decreased (P=0.047 and 0.043, respectively). No patients needed a dose reduction or treatment discontinuation of esaxerenone based on the serum potassium and eGFR criteria. UACR and BNP decreased insignificantly. The responders were significantly older than the nonresponders of the esaxerenone treatment (P=0.0035). Conclusions Esaxerenone was effective in older patients with primary aldosteronism.
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24
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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25
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Zhou Y, Liu Q, Wang X, Wan J, Liu S, Luo T, He P, Hou J, Pu J, Wang D, Liang D, Yang Y, Wang P. Adrenal Ablation Versus Mineralocorticoid Receptor Antagonism for the Treatment of Primary Aldosteronism: A Single-Center Prospective Cohort Study. Am J Hypertens 2022; 35:1014-1023. [PMID: 36205513 DOI: 10.1093/ajh/hpac105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/21/2022] [Accepted: 09/13/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Superselective adrenal arterial embolization (SAAE) is an alternative treatment for patients with primary aldosteronism (PA). This single-center prospective cohort study aimed to compare the efficacy of SAAE with mineralocorticoid receptor antagonists (MRA) in treating patients with PA who refused unilateral adrenalectomy. METHODS Of the 140 PA patients who were enrolled in the study and completed 12-month follow-up, 74 patients underwent SAAE and 66 received MRA treatment. The clinical and biochemical outcome was compared at 1, 6, and 12 months after the procedure. RESULTS Baseline clinical and biochemical characteristics of the patients were similar between groups. Office, home, and ambulatory blood pressure reduction at 1 month after discharge was more pronounced in the SAAE group than MRA group (all P < 0.05) while the blood pressure reduction was comparable between the 2 groups at 6 and 12 months. Patients who underwent SAAE took less antihypertensive medications than the MRA group during 12-month follow-up (P < 0.01). Both SAAE and MRA treatment improved renin suppression, aldosterone-to-renin ratio elevation, and hypokalemia at 6 and 12 months, whereas only SAAE but not MRA reduced plasma aldosterone levels. Moreover, SAAE achieved higher rates of complete clinical and biochemical success than MRA (both P < 0.01). Logistic regression found that complete clinical and biochemical success was only directly associated with diagnosis of unilateral PA in contrast to bilateral PA (P < 0.01). CONCLUSIONS The present study provides evidence that SAAE is a reasonable choice of treatment in patients with either unilateral or bilateral PA in terms of clinical and biochemical outcomes. This study was registered at Chictr.org.cn (ChiCTR2100045896).
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Affiliation(s)
- Yaqiong Zhou
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Qiting Liu
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Xinquan Wang
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Jindong Wan
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Sen Liu
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Tao Luo
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Ping He
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Jixin Hou
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Jing Pu
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Dan Wang
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Dengpan Liang
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Yi Yang
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
| | - Peijian Wang
- Department of Cardiology, Clinical Medical College and The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Sichuan Clinical Research Center for Geriatrics, The First Affiliated Hospital of Chengdu Medical College, Chengdu, Sichuan 610500, China.,Key Laboratory of Aging and Vascular Homeostasis of Sichuan Higher Education Institutes, Chengdu, Sichuan 610500, China
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26
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Chen SY, Chen JY, Huang WC, Puar THK, Chin Kek P, Chueh JS, Lin YH, Wu VC, Study Group T. Cardiovascular outcomes and all-cause mortality in primary aldosteronism after adrenalectomy or mineralocorticoid receptor antagonist treatment: a meta-analysis. Eur J Endocrinol 2022; 187:S47-S58. [PMID: 36315466 DOI: 10.1530/eje-22-0375] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 10/31/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND In patients with primary aldosteronism (PA), long-term cardiovascular and mortality outcomes after adrenalectomy vs mineralocorticoid receptor antagonist (MRA) have not been compared yet. We aim to compare the clinical outcomes of these patients after treatment. DESIGN AND METHODS A systematic review and meta-analysis was conducted by searching PubMed, Cochrane library, and Embase from no start date restriction to 18 December 2021. Our composite primary outcomes were long-term all-cause mortality and/or major adverse cardiovascular events (MACE), including coronary artery disease (CAD), stroke, arrhythmia, and congestive heart failure. We adopted the random-effects model and performed subgroup analyses, meta-regression, and trial sequential analysis (TSA). RESULTS A total of 9 studies with 8473 adult patients with PA (≥18 years) were enrolled. A lower incidence of composite primary outcomes was observed in the adrenalectomy group (odds ratio (OR): 0.46 (95% CI: 0.38-0.56), P < 0.001). We found a lower incidence of all-cause mortality (OR: 0.33 (95% CI: 0.15-0.73), P = 0.006) and MACE (OR: 0.55, (95% CI: 0.40-0.74), P = 0.0001) in the adrenalectomy group. The incidence of CAD (OR: 0.33 (95% CI: 0.15-0.75), P = 0.008), arrhythmias (OR: 0.46 (95% CI: 0.27-0.81), P = 0.007), and congestive heart failure (OR: 0.52 (95% CI: 0.33-0.81), P = 0.004) was also lower in adrenalectomy group. The metaregression showed patient's age may attenuate the benefits of adrenalectomy on composite primary outcomes (coefficient: 1.084 (95% CI: 1.005-1.169), P = 0.036). TSA demonstrated that the accrued sample size and effect size were sufficiently large to draw a solid conclusion, and the advantage of adrenalectomy over MRA was constant with the chronological sequence. CONCLUSIONS In conclusion, adrenalectomy could be preferred over MRA for patients with PA in reducing the risk of all-cause mortality and/or MACE and should be considered as the treatment of choice. That patients with PA could get less benefit from adrenalectomy as they age warrants further investigation.
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Affiliation(s)
- Sheng-Yin Chen
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jui-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Chi Mei Medical Center, Tainan, Taiwan
| | - Wei-Chieh Huang
- Division of Cardiology, Department of Internal Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Troy Hai Kiat Puar
- Department of Endocrinology, Changi General Hospital, SingHealth, Singapore
| | - Peng Chin Kek
- Department of Endocrinology, Singapore General Hospital, Singapore
| | - Jeff S Chueh
- Department of Urology, National Taiwan University Hospital and College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taiwan
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taiwan
| | - Taipai Study Group
- TAIPAI, Taiwan Primary Aldosteronism Investigation (TAIPAI) Study Group, Taiwan
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27
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Imaging or Adrenal Vein Sampling Approach in Primary Aldosteronism? A Patient-Based Approach. Tomography 2022; 8:2735-2748. [PMID: 36412687 PMCID: PMC9680373 DOI: 10.3390/tomography8060228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/11/2022] Open
Abstract
Primary aldosteronism (PA) is the most frequent cause of secondary hypertension, associated with an increased risk of cardiovascular and cerebral disease, compared to essential hypertension. Therefore, it is mandatory to promptly recognize the disease and offer to the patient the correct diagnostic-therapeutic process in order to reduce new-onset cardiovascular events. It is fundamental to define subtype classification (unilateral or bilateral disease), in order to provide the best treatment (surgery for unilateral and medical treatment for bilateral disease). Here, we report five clinical cases of different subtypes of PA (patients with monolateral or bilateral PA, nondiagnostic AVS, allergy to iodinated contrast, and patients not suitable for surgery), with particular attention to the diagnostic-therapeutic process and the different approaches tailored to a single case. Since PA is a spectrum of various diseases, it needs a personalized diagnostic-therapeutic process, customized for the individual patient, depending on previous medical history, suitability for the surgery and patient's preferences.
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Heinrich DA, Quinkler M, Adolf C, Handgriff L, Müller L, Schneider H, Sturm L, Künzel H, Seidensticker M, Deniz S, Ladurner R, Beuschlein F, Reincke M. Influence of cortisol cosecretion on non-ACTH-stimulated adrenal venous sampling in primary aldosteronism: a retrospective cohort study. Eur J Endocrinol 2022; 187:637-650. [PMID: 36070424 DOI: 10.1530/eje-21-0541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 09/07/2022] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Cortisol measurements are essential for the interpretation of adrenal venous samplings (AVS) in primary aldosteronism (PA). Cortisol cosecretion may influence AVS indices. We aimed to investigate whether cortisol cosecretion affects non-adrenocorticotrophic hormone (ACTH)-stimulated AVS results. DESIGN Retrospective cohort study at a tertiary referral center. METHODS We analyzed 278 PA patients who underwent non-ACTH-stimulated AVS and had undergone at least a 1-mg dexamethasone suppression test (DST). Subsets underwent additional late-night salivary cortisol (LSC) and/or 24-h urinary free cortisol (UFC) measurements. Patients were studied from 2013 to 2020 with follow-up data of 6 months following adrenalectomy or mineralocorticoid antagonist therapy initiation. We analyzed AVS parameters including adrenal vein aldosterone/cortisol ratios, selectivity, lateralization (LI) and contralateral suppression indices and post-operative ACTH-stimulation. We classified outcomes according to the primary aldosteronism surgical outcome (PASO) criteria. RESULTS Among the patients, 18.9% had a pathological DST result (1.9-5 µg/dL: n = 44 (15.8%); >5 µg/dL: n = 8 (2.9%)). Comparison of AVS results stratified according to the 1-mg DST (≤1.8 vs >1.8 µg/dL: P = 0.499; ≤1.8 vs 1.8 ≤ 5 vs >5 µg/dL: P = 0.811) showed no difference. Lateralized cases with post DST serum cortisol values > 5 µg/dL had lower LI (≤1.8 µg/dL: 11.11 (5.36; 26.76) vs 1.9-5 µg/dL: 11.76 (4.9; 31.88) vs >5 µg/dL: 2.58 (1.67; 3.3); P = 0.008). PASO outcome was not different according to cortisol cosecretion. CONCLUSIONS Marked cortisol cosecretion has the potential to influence non-ACTH-stimulated AVS results. While this could result in falsely classified lateralized cases as bilateral, further analysis of substitutes for cortisol are required to unmask effects on clinical outcome.
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Affiliation(s)
| | | | - Christian Adolf
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Laura Handgriff
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Lisa Müller
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Holger Schneider
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Lisa Sturm
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Heike Künzel
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
| | - Max Seidensticker
- Klinik und Poliklinik für Radiologie, LMU Klinikum, LMU München, Munich, Germany
| | - Sinan Deniz
- Klinik und Poliklinik für Radiologie, LMU Klinikum, LMU München, Munich, Germany
| | - Roland Ladurner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, LMU Klinikum, Munich, Germany
| | - Felix Beuschlein
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
- Klinik für Endokrinologie, Diabetologie und Klinische Ernährung, UniversitätsSpital Zürich (USZ) and Universität Zürich (UZH), Zurich, Switzerland
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, LMU Klinikum, Munich, Germany
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Januszewicz A, Mulatero P, Dobrowolski P, Monticone S, Van der Niepen P, Sarafidis P, Reincke M, Rexhaj E, Eisenhofer G, Januszewicz M, Kasiakogias A, Kreutz R, Lenders JW, Muiesan ML, Persu A, Agabiti-Rosei E, Soria R, Śpiewak M, Prejbisz A, Messerli FH. Cardiac Phenotypes in Secondary Hypertension. J Am Coll Cardiol 2022; 80:1480-1497. [DOI: 10.1016/j.jacc.2022.08.714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 11/06/2022]
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Abstract
Besides the physiological regulation of water, sodium, and potassium homeostasis, aldosterone modulates several physiological and pathological processes in the cardiovascular system. At the vascular level, aldosterone excess stimulates endothelial dysfunction and infiltration of inflammatory cells, enhances the development of the atherosclerotic plaque, and favors plaque instability, arterial stiffness, and calcification. At the cardiac level, aldosterone increases cardiac inflammation, fibrosis, and myocardial hypertrophy. As a clinical consequence, high aldosterone levels are associated with enhanced risk of cardiovascular events and mortality, especially when aldosterone secretion is inappropriate for renin levels and sodium intake, as in primary aldosteronism. Several clinical trials showed that mineralocorticoid receptor antagonists reduce cardiovascular mortality in patients with heart failure and reduced ejection fraction, but inconclusive results were reported for other cardiovascular conditions, such as heart failure with preserved ejection fraction, myocardial infarction, and atrial fibrillation. In patients with primary aldosteronism, adrenalectomy or treatment with mineralocorticoid receptor antagonists significantly mitigate adverse aldosterone effects, reducing the risk of cardiovascular events, mortality, and incident atrial fibrillation. In this review, we will summarize the major preclinical and clinical studies investigating the cardiovascular damage mediated by aldosterone and the protective effect of mineralocorticoid receptor antagonists for the reduction of cardiovascular risk in patients with cardiovascular diseases and primary aldosteronism.
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Affiliation(s)
- Fabrizio Buffolo
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Martina Tetti
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Italy
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Assessment of cardiovascular disease risk by plasma renin activity changes in patients with primary aldosteronism on mineralocorticoid receptor antagonist treatment. Hypertens Res 2022; 45:1517-1519. [PMID: 35835999 DOI: 10.1038/s41440-022-00979-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/12/2022] [Indexed: 11/08/2022]
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33
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Turcu AF, Nhan W, Grigoryan S, Zhang L, Urban C, Liu H, Holevinski L, Zhao L. Primary Aldosteronism Screening Rates Differ with Sex, Race, and Comorbidities. J Am Heart Assoc 2022; 11:e025952. [PMID: 35861830 PMCID: PMC9707846 DOI: 10.1161/jaha.122.025952] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background
Primary aldosteronism (PA) is a common but under‐recognized cause of secondary hypertension. Data directly comparing screening rates across single and overlapping indications are lacking.
Methods and Results
We conducted a retrospective review of adults with hypertension seen in outpatient clinics at a tertiary referral academic center between January 1, 2017, and June 30, 2020. We included patients with hypertension plus at least one of the following: resistant hypertension; age<35 years; obstructive sleep apnea; hypokalemia; or an adrenal mass. We excluded patients with adrenal insufficiency, severe renal disease, or heart failure, and renovascular hypertension. Of 203 535 patients with hypertension, 86044 (42.3%) met at least 1 PA screening criterion, and of these, 2898 (3.4%) were screened for PA. Screening occurred in 2.7% of patients with resistant hypertension; 4.2% of those with obstructive sleep apnea; 5.1% of those <35 years; 10.0% of those with hypokalemia; and 47.3% of patients with an adrenal mass. Screening rates were higher in patients with multiple risk factors: 16.8% for ≥3, 5.7% for 2, and 2.5% for 1 criterion. Multiple logistic regression showed that the odds of PA screening were higher in patients with hypokalemia: odds ratio (95% CI): 3.0 (2.7–3.3); women: 1.3 (1.2–1.4); Black versus White: 1.5 (1.4–1.7); those with obstructive sleep apnea, chronic renal disease, stroke, and dyslipidemia.
Conclusions
Consideration for PA is given in a small subset of at‐risk patients, and typically after comorbidities have developed.
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Affiliation(s)
- Adina F. Turcu
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Winnie Nhan
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Seda Grigoryan
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Lei Zhang
- School of Public Health University of Michigan Ann Arbor MI
| | - Caitlin Urban
- Michigan State University College of Human Medicine East Lansing MI
| | - Haiping Liu
- Division of Metabolism, Endocrinology, and Diabetes University of Michigan Ann Arbor MI
| | - Lynn Holevinski
- University of Michigan Medical School, Data Office for Clinical and Translational Research Ann Arbor MI
| | - Lili Zhao
- School of Public Health University of Michigan Ann Arbor MI
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Nomura M, Kurihara I, Itoh H, Ichijo T, Katabami T, Tsuiki M, Wada N, Yoneda T, Sone M, Oki K, Yamada T, Kobayashi H, Tamura K, Ogawa Y, Inagaki N, Yamamoto K, Otsuki M, Yabe D, Izawa S, Takahashi Y, Suzuki T, Yasoda A, Tanabe A, Naruse M. Association of cardiovascular disease risk and changes in renin levels by mineralocorticoid receptor antagonists in patients with primary aldosteronism. Hypertens Res 2022; 45:1476-1485. [PMID: 35764671 DOI: 10.1038/s41440-022-00960-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 04/14/2022] [Accepted: 04/26/2022] [Indexed: 11/09/2022]
Abstract
A recent report stated that patients with primary aldosteronism who remain renin suppressed during mineralocorticoid receptor antagonist treatment might have a higher risk of developing cardiovascular disease than those with unsuppressed renin activity. We retrospectively investigated the incidence of composite cardiovascular disease and risk factors for cardiovascular disease in 1115 Japanese patients with primary aldosteronism treated with mineralocorticoid receptor antagonists. The median follow-up period was 3.0 years, and the incidence of cardiovascular events was very low (2.1%) throughout 5 years of follow-up. Changes in plasma renin activity from before to after mineralocorticoid receptor antagonist treatment were divided into three groups based on tertile, low, intermediate, and high plasma renin activity change groups, with incidences of cardiovascular disease events of 2.1%, 0.5%, and 3.7%, respectively. Multivariate Cox regression analysis revealed age (adjusted hazard ratio, 1.07; 95% confidence interval, [1.02-1.12]) and body mass index (adjusted hazard ratio, 1.13 [1.04-1.23]) as independent risk factors for cardiovascular disease. The high plasma renin activity change group had significantly higher cardiovascular disease risk with mineralocorticoid receptor antagonist treatment than the intermediate plasma renin activity change group (adjusted hazard ratio, 5.71 [1.28-25.5]). These data suggest that a high change in renin level after mineralocorticoid receptor antagonist treatment may not necessarily predict a better prognosis of cardiovascular disease in patients with primary aldosteronism.
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Affiliation(s)
- Motoko Nomura
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan
| | - Isao Kurihara
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan. .,Department of Medical Education, National Defense Medical College, Tokorozawa, Japan.
| | - Hiroshi Itoh
- Department of Endocrinology, Metabolism and Nephrology, School of Medicine Keio University, Tokyo, Japan
| | - Takamasa Ichijo
- Department of Endocrinology and Metabolism, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Takuyuki Katabami
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St Marianna University School Yokohama City Seibu Hospital, Yokohama, Japan
| | - Mika Tsuiki
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Norio Wada
- Department of Diabetes and Endocrinology, Sapporo City General Hospital, Sapporo, Japan
| | - Takashi Yoneda
- Department of Internal Medicine, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Masakatsu Sone
- Division of Metabolism and Endocrinology, Department of Internal Medicine, St Marianna University School of Medicine, Kawasaki, Japan
| | - Kenji Oki
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Tetsuya Yamada
- Department of Molecular Endocrinology and Metabolism, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Hiroki Kobayashi
- Division of Nephrology, Hypertension, and Endocrinology, Nihon University School of Medicine, Tokyo, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiovascular Medicine, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Yoshihiro Ogawa
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Nobuya Inagaki
- Department of Diabetes, Endocrinology and Nutrition, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Koichi Yamamoto
- Department of Geriatric and General Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Michio Otsuki
- Department of Endocrinology, Tokyo Women's Medical University, Tokyo, Japan.,Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Yabe
- Department of Diabetes, Endocrinology and Metabolism, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Shoichiro Izawa
- Division of Endocrinology and Metabolism, Tottori University Faculty of Medicine, Yonago, Japan
| | - Yutaka Takahashi
- Department of Diabetes and Endocrinology, Nara Medical University, Kashihara, Japan
| | - Tomoko Suzuki
- Department of Public Health, International University of Health and Welfare School of Medicine, Chiba, Japan
| | - Akihiro Yasoda
- Clinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Akiyo Tanabe
- Division of Endocrinology, National Center for Global Health and Medicine, Tokyo, Japan
| | - Mitsuhide Naruse
- Clinical Research Center, National Hospital Organization Kyoto Medical Center, Kyoto, Japan.,Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
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Araujo-Castro M, Paja Fano M, González Boillos M, Pla Peris B, Pascual-Corrales E, García Cano AM, Parra Ramírez P, Rojas-Marcos PM, Ruiz-Sanchez JG, Vicente Delgado A, Gómez Hoyos E, Ferreira R, García Sanz I, Díaz Guardiola P, García González JJ, Perdomo CM, Morales M, Hanzu FA. Evolution of the cardiometabolic profile of primary hyperaldosteronism patients treated with adrenalectomy and with mineralocorticoid receptor antagonists: results from the SPAIN-ALDO Registry. Endocrine 2022; 76:687-696. [PMID: 35275344 DOI: 10.1007/s12020-022-03029-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/22/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the evolution of the cardiometabolic profile of patients with primary hyperaldosteronism (PA) after the treatment with surgery and with mineralocorticoid receptor antagonists (MRA). DESIGN Retrospective multicentric study of patients with PA on follow-up in twelve Spanish centers between 2018 and 2020. RESULTS 268 patients with PA treated by surgery (n = 100) or with MRA (n = 168) were included. At baseline, patients treated with surgery were more commonly women (54.6% vs 41.7%, P = 0.042), had a higher prevalence of hypokalemia (72.2% vs 58%, P = 0.022) and lower prevalence of obesity (37.4% vs 51.3%, P = 0.034) than patients treated with MRA. Adrenalectomy resulted in complete biochemical cure in 94.0% and clinical response in 83.0% (complete response in 41.0% and partial response in 42.0%). After a median follow-up of 23.6 (IQR 9.7-53.8) months, the reduction in blood pressure (BP) after treatment was similar between the group of surgery and MRA, but patients surgically treated reduced the number of antihypertensive pills for BP control more than those medically treated (∆antihypertensives: -1.3 ± 1.3 vs 0.0 ± 1.4, P < 0.0001) and experienced a higher increased in serum potassium levels (∆serum potassium: 0.9 ± 0.7 vs 0.6 ± 0.8mEq/ml, P = 0.003). However, no differences in the risk of the onset of new renal and cardiometabolic comorbidities was observed between the group of surgery and MRA (HR = 0.9 [0.5-1.5], P = 0.659). CONCLUSION In patients with PA, MRA and surgery offer a similar short-term cardiovascular protection, but surgery improves biochemical control and reduces pill burden more commonly than MRA, and lead to hypertension cure or improvement in up to 83% of the patients.
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Affiliation(s)
- Marta Araujo-Castro
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain.
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain.
- University of Alcalá, Madrid, Spain.
| | - Miguel Paja Fano
- Endocrinology & Nutrition Department, Hospital Universitario de Basurto, Bilbao, Spain
| | - Marga González Boillos
- Endocrinology & Nutrition Department, Hospital Universitario de Castellón, Castellón, Spain
| | - Begoña Pla Peris
- Endocrinology & Nutrition Department, Hospital Universitario de Castellón, Castellón, Spain
| | - Eider Pascual-Corrales
- Endocrinology & Nutrition Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Instituto de Investigación Biomédica Ramón y Cajal (IRYCIS), Madrid, Spain
| | | | - Paola Parra Ramírez
- Endocrinology & Nutrition Department, Hospital Universitario La Paz Madrid, Madrid, Spain
| | | | | | | | - Emilia Gómez Hoyos
- Endocrinology & Nutrition Department, Hospital Universitario de Valladolid, Valladolid, Spain
| | - Rui Ferreira
- Endocrinology & Nutrition Department, Hospital Universitario de La Princesa, Madrid, Spain
| | - Iñigo García Sanz
- General & Digestive Surgery Department, Hospital Universitario de La Princesa, Madrid, Spain
| | | | | | - Carolina M Perdomo
- Endocrinology & Nutrition Department, Clínica Universidad de Navarra, Pamplona, Spain
| | - Manuel Morales
- Biochemistry Department, Hospital Clinic, Barcelona, Spain
| | - Felicia A Hanzu
- Endocrinology & Nutrition Department, Hospital Clinic, Barcelona, Spain
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Stavropoulos K, Imprialos KP, Patoulias D, Katsimardou A, Doumas M. Impact of Primary Aldosteronism in Resistant Hypertension. Curr Hypertens Rep 2022; 24:285-294. [PMID: 35445928 DOI: 10.1007/s11906-022-01190-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE OF REVIEW In this narrative review, we aim to summarize the latest data on the association between primary aldosteronism and resistant hypertension, as well as to emphasize the necessity for screening for primary aldosteronism all patients with resistant hypertension. RECENT FINDINGS Epidemiological data suggests that up to one out of five patients with resistant hypertension suffer from primary aldosteronism. Patients with primary aldosteronism have increased incidence of renal disease, diabetes mellitus, atrial fibrillation, and obstructive sleep apnea, as well as they are characterized by an extended target organ damage and increased cardiovascular morbidity and mortality. Specific treatments for primary hyperaldosteronism (adrenalectomy and mineralocorticoid receptor antagonists) have significant impact on blood pressure, can reverse target organ damage, and mitigate cardiovascular risk. All patients with resistant hypertension should be evaluated for primary aldosteronism. Patients diagnosed with the disease may further undergo lateralization with adrenal vein sampling in order to receive the optimal therapeutic option which results in significant improvements in quality of life and cardiovascular profile.
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Affiliation(s)
| | | | - Dimitrios Patoulias
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Alexandra Katsimardou
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
| | - Michael Doumas
- 2nd Propedeutic Department of Internal Medicine, Aristotle University, Thessaloniki, Greece
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Marazzato J, Blasi F, Golino M, Verdecchia P, Angeli F, De Ponti R. Hypertension and Arrhythmias: A Clinical Overview of the Pathophysiology-Driven Management of Cardiac Arrhythmias in Hypertensive Patients. J Cardiovasc Dev Dis 2022; 9:jcdd9040110. [PMID: 35448086 PMCID: PMC9025699 DOI: 10.3390/jcdd9040110] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 03/26/2022] [Accepted: 04/02/2022] [Indexed: 02/06/2023] Open
Abstract
Because of demographic aging, the prevalence of arterial hypertension (HTN) and cardiac arrhythmias, namely atrial fibrillation (AF), is progressively increasing. Not only are these clinical entities strongly connected, but, acting with a synergistic effect, their association may cause a worse clinical outcome in patients already at risk of ischemic and/or haemorrhagic stroke and, consequently, disability and death. Despite the well-known association between HTN and AF, several pathogenetic mechanisms underlying the higher risk of AF in hypertensive patients are still incompletely known. Although several trials reported the overall clinical benefit of renin–angiotensin–aldosterone inhibitors in reducing incident AF in HTN, the role of this class of drugs is greatly reduced when AF diagnosis is already established, thus hinting at the urgent need for primary prevention measures to reduce AF occurrence in these patients. Through a thorough review of the available literature in the field, we investigated the basic mechanisms through which HTN is believed to promote AF, summarising the evidence supporting a pathophysiology-driven approach to prevent this arrhythmia in hypertensive patients, including those suffering from primary aldosteronism, a non-negligible and under-recognised cause of secondary HTN. Finally, in the hazy scenario of AF screening in hypertensive patients, we reviewed which patients should be screened, by which modality, and who should be offered oral anticoagulation for stroke prevention.
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Affiliation(s)
- Jacopo Marazzato
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (M.G.); (F.A.)
| | - Federico Blasi
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (M.G.); (F.A.)
| | - Michele Golino
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (M.G.); (F.A.)
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS, 06100 Perugia, Italy;
- Division of Cardiology, Hospital S. Maria della Misericordia, 06100 Perugia, Italy
| | - Fabio Angeli
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (M.G.); (F.A.)
- Department of Medicine and Cardiopulmonary Rehabilitation, Maugeri Care and Research Institute, IRCCS Tradate, 21049 Tradate, Italy
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, 21100 Varese, Italy; (J.M.); (F.B.); (M.G.); (F.A.)
- Correspondence: ; Tel.: +39-0332278934
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Persistent cardiac organ damage in surgically and medically treated primary aldosteronism. J Hypertens 2022; 40:1204-1211. [DOI: 10.1097/hjh.0000000000003135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Chauhan K, Schachna E, Libianto R, Ryan J, Hutton H, Fuller PJ, Wilson S, Kerr PG, Yang J. Screening for primary aldosteronism is underutilised in patients with chronic kidney disease. J Nephrol 2022; 35:1667-1677. [PMID: 35195879 PMCID: PMC9300536 DOI: 10.1007/s40620-022-01267-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 02/01/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common and potentially curable endocrine cause of secondary hypertension, and carries a worse prognosis than essential hypertension. Despite the high prevalence of hypertension in patients with chronic kidney disease (CKD), the screening rates for primary aldosteronism in CKD are unknown. METHODS In this study, we retrospectively reviewed medical records of 1627 adults who presented to the nephrology clinics of 2 tertiary hospitals in Melbourne, Australia, between 2014 and 2019. In addition to assessing the pattern of screening, we also evaluated patient-specific factors associated with the decision to test for primary aldosteronism. Patients were excluded from the final analysis if they did not have CKD, had an organ transplant, had end stage renal failure, or had insufficient data or follow-up. RESULTS Of the 600 patients included in the analysis, 234 (39%) had an indication for screening for primary aldosteronism based on recommendations made by the Endocrine Society. However, only 33 (14%) were tested. They were younger, had a higher mean systolic blood pressure, better renal function, and lower mean serum potassium than those who were indicated but not screened. Of the 33 screened patients, an elevated aldosterone-to-renin ratio was noted in 8 patients and a diagnosis of primary aldosteronism was made in 4 patients. CONCLUSIONS The screening rate for primary aldosteronism is low in a CKD population, especially in patients who are older, have a lower eGFR and normal serum potassium. The consequences of undiagnosed primary aldosteronism in this select population may be substantial due to the cardiovascular and renal sequelae associated with untreated disease.
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Affiliation(s)
| | - Eitan Schachna
- Central Clinical School, Monash University, Clayton, Australia
| | - Renata Libianto
- Department of Endocrinology, Monash Health, Clayton, Australia
- Endocrine Hypertension Group, Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Level 3, Block E, Monash Medical Centre, Clayton Road, Clayton, VIC, 3168, Australia
| | - Jessica Ryan
- School of Clinical Sciences, Monash University, Clayton, Australia
- Department of Nephrology, Monash Health, Clayton, Australia
| | - Holly Hutton
- Central Clinical School, Monash University, Clayton, Australia
- Department of Nephrology, Alfred Health, Melbourne, Australia
| | - Peter J Fuller
- Department of Endocrinology, Monash Health, Clayton, Australia
- Endocrine Hypertension Group, Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Level 3, Block E, Monash Medical Centre, Clayton Road, Clayton, VIC, 3168, Australia
| | - Scott Wilson
- Central Clinical School, Monash University, Clayton, Australia
- Department of Nephrology, Alfred Health, Melbourne, Australia
| | - Peter G Kerr
- School of Clinical Sciences, Monash University, Clayton, Australia
- Department of Nephrology, Monash Health, Clayton, Australia
| | - Jun Yang
- School of Clinical Sciences, Monash University, Clayton, Australia.
- Department of Endocrinology, Monash Health, Clayton, Australia.
- Endocrine Hypertension Group, Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Level 3, Block E, Monash Medical Centre, Clayton Road, Clayton, VIC, 3168, Australia.
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Atrial Fibrillation and Aortic Ectasia as Complications of Primary Aldosteronism: Focus on Pathophysiological Aspects. Int J Mol Sci 2022; 23:ijms23042111. [PMID: 35216224 PMCID: PMC8875197 DOI: 10.3390/ijms23042111] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 02/07/2022] [Accepted: 02/12/2022] [Indexed: 11/22/2022] Open
Abstract
Primary aldosteronism (PA) is the most common cause of secondary hypertension. A growing body of evidence has suggested that, beyond its well-known effects on blood pressure and electrolyte balance, aldosterone excess can exert pro-inflammatory, pro-oxidant and pro-fibrotic effects on the kidney, blood vessels and heart, leading to potentially harmful pathophysiological consequences. In clinical studies, PA has been associated with an increased risk of cardiovascular, cerebrovascular, renal and metabolic complication compared to essential hypertension, including atrial fibrillation (AF) and aortic ectasia. An increased prevalence of AF in patients with PA has been demonstrated in several clinical studies. Aldosterone excess seems to be involved in the pathogenesis of AF by inducing cardiac structural and electrical remodeling that in turn predisposes to arrhythmogenicity. The association between PA and aortic ectasia is less established, but several studies have demonstrated an effect of aldosterone on aortic stiffness, vascular smooth muscle cells and media composition that, in turn, might lead to an increased risk of aortic dilation and dissection. In this review, we focus on the current evidence regarding the potential role of aldosterone excess in the pathogenesis of AF and aortic ectasia.
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Lin X, Ullah MHE, Wu X, Xu F, Shan SK, Lei LM, Yuan LQ, Liu J. Cerebro-Cardiovascular Risk, Target Organ Damage, and Treatment Outcomes in Primary Aldosteronism. Front Cardiovasc Med 2022; 8:798364. [PMID: 35187110 PMCID: PMC8847442 DOI: 10.3389/fcvm.2021.798364] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023] Open
Abstract
Primary aldosteronism (PA) is the most common type of endocrine hypertension, and numerous experimental and clinical evidence have verified that prolonged exposure to excess aldosterone is responsible for an increased risk of cerebro-cardiovascular events and target organ damage (TOD) in patients with PA. Therefore, focusing on restoring the toxic effects of excess aldosterone on the target organs is very important to reduce cerebro-cardiovascular events. Current evidence convincingly demonstrates that both surgical and medical treatment strategies would benefit cerebro-cardiovascular outcomes and mortality in the long term. Understanding cerebro-cardiovascular risk in PA would help clinical doctors to achieve both early diagnosis and treatment. Therefore, in this review, we will summarize the cerebro-cardiovascular risk in PA, focusing on the TOD of aldosterone, including brain, heart, vascular system, renal, adipose tissues, diabetes, and obstructive sleep apnea (OSA). Furthermore, the various treatment outcomes of adrenalectomy and medical treatment for patients with PA will also be discussed. We hope this knowledge will help improve cerebro-cardiovascular prognosis and reduce the incidence and mortality of cerebro-cardiovascular events in patients with PA.
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Affiliation(s)
- Xiao Lin
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Muhammad Hasnain Ehsan Ullah
- Department of Endocrinology and Metabolism, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Xiong Wu
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Feng Xu
- Department of Endocrinology and Metabolism, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Su-Kang Shan
- Department of Endocrinology and Metabolism, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Li-Min Lei
- Department of Endocrinology and Metabolism, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Ling-Qing Yuan
- Department of Endocrinology and Metabolism, National Clinical Research Center for Metabolic Diseases, The Second Xiangya Hospital, Central South University, Changsha, China
- Ling-Qing Yuan
| | - Jun Liu
- Department of Radiology, The Second Xiangya Hospital, Central South University, Changsha, China
- Clinical Research Center for Medical Imaging in Hunan Province, Changsha, China
- Department of Radiology Quality Control Center in Hunan Province, Changsha, China
- *Correspondence: Jun Liu
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Asbach E, Reincke M. [Diagnosis and therapy of primary aldosteronism: new aspects]. Dtsch Med Wochenschr 2022; 147:92-97. [PMID: 35100641 DOI: 10.1055/a-1370-5935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Primary aldosteronism represents the most frequent cause of endocrine hypertension. It is associated with a higher morbidity and mortality compared to essential hypertension. Early identification of the affected patients is crucial, as the adequate therapy leads to an excellent long-term prognosis, especially after unilateral adrenalectomy. Diagnosis consists of three steps: diagnosis, confirmation test and subtype differentiation. The 2 most frequent causes of primary aldosteronism are aldosterone producing adenoma, which can be cured by surgery, and idiopathic bilateral adrenal hyperplasia, which is treated with mineralocorticoid receptor antagonists.Screening by aldosterone-to-renin ratio is recommended in designed risk populations. As the aldosterone-to-renin ratio displays a limited sensitivity and specificity, confirmatory testing is recommended in most patients with positive screening test. Prediction scores allow to skip confirmatory testing under certain circumstances. Adrenal vein sampling still represents the gold standard in subtype differentiation of primary aldosteronism. Steroid profiling could possibly make dispensable adrenal vein sampling in patients with bilateral hyperplasia. Different studies investigate the potential of functional imaging for differential diagnosis of primary aldosteronism.
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Primary Hyperaldosteronism: When to Suspect It and How to Confirm Its Diagnosis. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The definition of primary hyperaldosteronism (PA) has shifted, as progress has been made in understanding the disease. PA can be produced by unilateral or bilateral cortical adrenal hyperproduction of aldosterone, due to hyperplasia, aldosterone-secreting cell clusters, aldosterone-producing macro or micro adenoma/s, and combinations of the above, or by an aldosterone-producing carcinoma. PA is a highly prevalent disease, affecting close to 10% of the hypertensive population. However, PA is clearly underdiagnosed. The purpose of this review is to address current knowledge of PA’s clinical manifestations, as well as current methods of diagnosis. PA is associated with a higher cardiovascular morbidity and mortality than essential hypertension with similar blood pressure control. Young hypertensive patients, those with a first-degree relative with PA or ictus, and/or those with apnea/hypopnea syndrome, moderate/severe/resistant hypertension, adrenal incidentaloma, and/or hypokalemia should be screened for PA. PA can induce atrial fibrillation (AF), and those patients should also be screened for PA. We propose the use of the Captopril challenge test (CCT), oral salt loading, or intravenous salt loading for PA diagnosis, given their availability in the majority of hospital centers. CCT could be first-line, since it is safe and easy to perform.
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Williams TA, Reincke M. Pathophysiology and histopathology of primary aldosteronism. Trends Endocrinol Metab 2022; 33:36-49. [PMID: 34743804 DOI: 10.1016/j.tem.2021.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 10/19/2022]
Abstract
Primary aldosteronism (PA) can be sporadic or familial and classified into unilateral and bilateral forms. Sporadic PA predominates with excessive aldosterone production usually arising from a unilateral aldosterone-producing adenoma (APA) or bilateral adrenocortical hyperplasia. Familial PA is rare and caused by germline variants, that partly correspond to somatic alterations in APAs. Classification into unilateral and bilateral PA determines the treatment approach but does not accurately mirror disease pathology. Some evidence indicates a disease continuum ranging from balanced aldosterone production from each adrenal to extreme asymmetrical bilateral aldosterone production. Nonetheless, surgical removal of the overactive adrenal in unilateral PA achieves highly successful outcomes and almost all patients are biochemically cured of their aldosteronism.
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Affiliation(s)
- Tracy Ann Williams
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany; Division of Internal Medicine and Hypertension, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
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Ahmed S, Hundemer GL. Benefits of Surgical Over Medical Treatment for Unilateral Primary Aldosteronism. Front Endocrinol (Lausanne) 2022; 13:861581. [PMID: 35557845 PMCID: PMC9086781 DOI: 10.3389/fendo.2022.861581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/28/2022] [Indexed: 11/26/2022] Open
Abstract
Primary aldosteronism is the most common and modifiable form of secondary hypertension. Left untreated, primary aldosteronism leads high rates of cardiovascular, metabolic, and kidney disease. Therefore, early diagnosis and targeted therapy are crucial to improve long-term patient outcomes. In the case of unilateral primary aldosteronism, surgical adrenalectomy is the guideline-recommended treatment of choice as compared to alternative medical therapies such as mineralocorticoid receptor antagonist medications. Surgical adrenalectomy is not only highly successful in reversing the biochemical abnormalities inherent to primary aldosteronism, but also in mitigating the long-term risks associated with this disease. Indeed, as opposed to medical treatment alone, surgical adrenalectomy offers the potential for disease cure. Within this review article, we review the existing evidence highlighting the benefits of surgical over medical treatment for unilateral primary aldosteronism.
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Affiliation(s)
- Sumaiya Ahmed
- Department of Medicine, Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| | - Gregory L. Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
- *Correspondence: Gregory L. Hundemer,
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Parasiliti-Caprino M, Bioletto F, Ceccato F, Lopez C, Bollati M, Di Carlo MC, Voltan G, Rossato D, Giraudo G, Scaroni C, Ghigo E, Maccario M. The Accuracy of Simple and Adjusted Aldosterone Indices for Assessing Selectivity and Lateralization of Adrenal Vein Sampling in the Diagnosis of Primary Aldosteronism Subtypes. Front Endocrinol (Lausanne) 2022; 13:801529. [PMID: 35250861 PMCID: PMC8888437 DOI: 10.3389/fendo.2022.801529] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/19/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE This study aimed to evaluate the reliability of simple and corrected aldosterone indices for assessing the selectivity and lateralization of adrenal vein sampling (AVS) in patients with primary aldosteronism. METHODS Data of all consecutive patients with primary aldosteronism who underwent AVS for subtype diagnosis, followed at two Italian referral centers, were analyzed retrospectively. RESULTS AVS achieved bilateral selectivity in 112/144 patients. Unilateral disease was diagnosed in 60 cases (53.6%) and idiopathic hyperaldosteronism in 52 individuals (46.4%). The aldosterone index (aldosterone ratio between an adrenal vein and the inferior vena cava) showed a high accuracy in predicting selectivity, compared to a cortisol selectivity index of 1.1, and a moderate accuracy, compared to cortisol cut-offs of 2 and 3. The simple aldosterone index showed a moderate accuracy in predicting ipsi/contralateral aldosterone hypersecretion, while lesion side- and hypokalemia-corrected aldosterone index revealed a significant improvement in predicting ipsi/contralateral disease. Moreover, the comparative aldosterone index (aldosterone ratio in the dominant vs the non-dominant adrenal vein) revealed a high accuracy in predicting unilateral primary aldosteronism. For an immediate clinical application of our results, the adjusted cut-offs were calculated, according to the Youden's criterion and to a pre-established specificity of 90%, for all possible combinations of lesion side at imaging and presence/absence of hypokalemia. CONCLUSIONS This study demonstrated the diagnostic accuracy of simple and clinical-/imaging-corrected aldosterone indices for adrenal vein sampling in subtype diagnosis of primary aldosteronism and suggests the potential application of these tools to select patients for adrenalectomy when standard indices cannot be performed.
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Affiliation(s)
- Mirko Parasiliti-Caprino
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
- *Correspondence: Mirko Parasiliti-Caprino, ; orcid.org/0000-0002-6930-7073
| | - Fabio Bioletto
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Filippo Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Chiara Lopez
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Martina Bollati
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Maria Chiara Di Carlo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Giacomo Voltan
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Denis Rossato
- Radiology Unit, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Giuseppe Giraudo
- Surgery, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Carla Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University-Hospital of Padua, Padua, Italy
| | - Ezio Ghigo
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
| | - Mauro Maccario
- Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, City of Health and Science University Hospital, University of Turin, Turin, Italy
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Kodintcev A. A clinical case of progressive hypokalemic myopathy due to Conn’s syndrome. Zh Nevrol Psikhiatr Im S S Korsakova 2022; 122:149-154. [DOI: 10.17116/jnevro2022122111149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Menut KCH, Pearlstein SS, Conroy PC, Roman SA, Shen WT, Gosnell J, Sosa JA, Duh QY, Suh I. Screening for primary aldosteronism in the hypertensive obstructive sleep apnea population is cost-saving. Surgery 2022; 171:96-103. [PMID: 34238603 PMCID: PMC9308489 DOI: 10.1016/j.surg.2021.05.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/08/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Guidelines recommend screening for primary aldosteronism in patients diagnosed with hypertension and obstructive sleep apnea. Recent studies have shown that adherence to these recommendations is extremely low. It has been suggested that cost is a barrier to implementation. No analysis has been done to rigorously evaluate the cost-effectiveness of widespread implementation of these guidelines. METHODS We constructed a decision-analytic model to evaluate screening of the hypertensive obstructive sleep apnea population for primary aldosteronism as per guideline recommendations in comparison with current rates of screening. Probabilities, utility values, and costs were identified in the literature. Threshold and sensitivity analyses assessed robustness of the model. Costs were represented in 2020 US dollars and health outcomes in quality-adjusted life-years. The model assumed a societal perspective with a lifetime time horizon. RESULTS Screening per guideline recommendations had an expected cost of $47,016 and 35.27 quality-adjusted life-years. Continuing at current rates of screening had an expected cost of $48,350 and 34.86 quality-adjusted life-years. Screening was dominant, as it was both less costly and more effective. These results were robust to sensitivity analysis of disease prevalence, test sensitivity, patient age, and expected outcome of medical or surgical treatment of primary aldosteronism. The screening strategy remained cost-effective even if screening were conservatively presumed to identify only 3% of new primary aldosteronism cases. CONCLUSIONS For patients with hypertension and obstructive sleep apnea, rigorous screening for primary aldosteronism is cost-saving due to cardiovascular risk averted. Cost should not be a barrier to improving primary aldosteronism screening adherence.
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Affiliation(s)
| | | | - Patricia C. Conroy
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Sanziana A. Roman
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Wen T. Shen
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Jessica Gosnell
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Julie Ann Sosa
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Quan-Yang Duh
- Section of Endocrine Surgery, University of California, San Francisco, CA
| | - Insoo Suh
- Division of Endocrine Surgery, New York University Langone Health, New York, NY,Reprint requests: Insoo Suh, MD, NYU Endocrine Surgery Associates, 530 1st Ave, Ste 6H New York, NY 10016. (I. Suh)
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Nguyen V, Tu TM, Mamauag MJB, Lai J, Saffari SE, Aw TC, Ong L, Foo RSY, Chai SC, Fones S, Zhang M, Puar TH. Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation. Front Endocrinol (Lausanne) 2022; 13:869980. [PMID: 35518929 PMCID: PMC9063461 DOI: 10.3389/fendo.2022.869980] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 03/07/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Primary aldosteronism (PA) is the most common cause of secondary hypertension, and patients are at an increased risk of atrial fibrillation (AF) and stroke. We assessed the prevalence of PA in patients with recent stroke. METHODS We recruited 300 patients admitted to an acute stroke unit with diagnosis of cerebrovascular accident (haemorrhagic/ischaemic) or transient ischaemic attack. Three months post-stroke, plasma renin and aldosterone were measured. Patients with an elevated aldosterone-renin ratio proceeded to the confirmatory saline loading test. RESULTS Twenty-six of 192 (14%) patients had an elevated aldosterone-renin ratio. Three of 14 patients who proceeded to saline loading were confirmed with PA (post-saline aldosterone >138 pmol/l). Another three patients were classified as confirmed/likely PA based on the markedly elevated aldosterone-renin ratio and clinical characteristics. The overall prevalence of PA amongst stroke patients with hypertension was 4.0% (95% confidence interval (CI): 0.9%-7.1%). Prevalence of PA was higher amongst patients with cardioembolic stroke, 11% (95% CI: 1.3%-33%), resistant hypertension, 11% (95% CI: 0.3%-48%), and hypertension and AF, 30% (95%CI: 6.7%-65%). If only young patients or those with hypokalaemia were screened for PA, half of our patients with PA would not have been diagnosed. Our decision tree identified that stroke patients with AF and diastolic blood pressure ≥83mmHg were most likely to have PA. CONCLUSION We found that amongst hypertensive patients with stroke, PA was more prevalent in those with AF, or cardioembolic stroke. Screening for PA should be considered for all patients with stroke.
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Affiliation(s)
- Van Nguyen
- Doctor of Medicine Programme, Duke National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
| | - Marlie Jane B Mamauag
- Department of Medicine, Neurology Division, Changi General Hospital (CGH), Singapore, Singapore
| | - Jovan Lai
- Bachelor of Medicine, Bachelor of Surgery Programme, Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Seyed Ehsan Saffari
- Department of Neurology, National Neuroscience Institute, Singapore, Singapore
- Health Services and Systems Research, Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Tar Choon Aw
- Department of Laboratory Medicine, CGH, Singapore, Singapore
| | - Lizhen Ong
- Department of Laboratory Medicine, National University Health System (NUHS), Singapore, Singapore
| | - Roger S Y Foo
- Genome Institute of Singapore, Singapore, Singapore
- Cardiovascular Research Institute, NUHS, Singapore, Singapore
| | | | - Shaun Fones
- Doctor of Medicine Programme, Duke National University of Singapore (NUS) Medical School, Singapore, Singapore
| | - Meifen Zhang
- Department of Endocrinology, CGH, Singapore, Singapore
| | - Troy H Puar
- Department of Endocrinology, CGH, Singapore, Singapore
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Parksook WW, Yozamp N, Hundemer GL, Moussa M, Underhill J, Fudim T, Sacks B, Vaidya A. Morphologically Normal-Appearing Adrenal Glands as a Prevalent Source of Aldosterone Production in Primary Aldosteronism. Am J Hypertens 2021; 35:561-571. [PMID: 34883509 PMCID: PMC9890245 DOI: 10.1093/ajh/hpab189] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/19/2021] [Accepted: 12/06/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Normal-appearing adrenal glands on cross-sectional imaging may still be the source of aldosterone production in primary aldosteronism (PA). METHODS We evaluated the prevalence of aldosterone production among morphologically normal-appearing adrenal glands and the impact of this phenomenon on interpretations of localization studies and treatment decisions. We performed a retrospective cohort study of PA patients with at least 1 normal adrenal gland and reanalyzed contemporary studies to assess interpretations of imaging and adrenal venous sampling (AVS) at the individual patient and adrenal levels. RESULTS Among 243 patients, 43 (18%) had bilateral normal-appearing adrenals and 200 (82%) had a unilateral normal-appearing adrenal, for a total of 286 normal-appearing adrenal glands. 38% of these normal-appearing adrenal glands were a source of aldosteronism on AVS, resulting in discordance between imaging and AVS findings in 31% of patients. Most patients with lateralizing PA underwent curative unilateral treatment (80%); however, curative treatment was pursued in 92% of patients who had concordant imaging-AVS results but in only 38% who had discordant results (P < 0.05). In young patients, imaging-AVS discordance was detected in 32% of those under 45 years and 21% of those under 35 years. Among 20 contemporary studies (including 4,904 patients and 6,934 normal-appearing adrenal glands), up to 64% of normal-appearing adrenals were a source of aldosteronism resulting in 31% of patients having discordant results. CONCLUSIONS Morphologically normal-appearing adrenal glands are commonly the source of aldosterone production in PA, even among young patients. The lack of awareness of this issue may result in inappropriate treatment recommendations.
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Affiliation(s)
- Wasita W Parksook
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA,Department of Medicine (Division of Endocrinology and Metabolism, and Division of General Internal Medicine), Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Nicholas Yozamp
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Marwan Moussa
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Underhill
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Tali Fudim
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Barry Sacks
- Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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