Cerebro-Cardiovascular Risk, Target Organ Damage, and Treatment Outcomes in Primary Aldosteronism

Effect of Age on Aldosterone-Renin Ratio in Screening Primary Aldosteronism

Primary aldosteronism (PA) is the most common endocrine cause of hypertension. The plasma aldosterone-to-renin ratio (ARR) is the most recommended screening tool for PA, but previous studies showed controversy regarding the influence of age on ARR. The aim of the study was to evaluate the impact of age on ARR measured using direct renin concentration (DRC) and its diagnostic value in patients with PA. We retrospectively collected patients with hypertension who attended Xiangya Hospital for PA screening using plasma aldosterone concentration (PAC)/DRC from January 1, 2017 to November 1, 2023. The patients were divided into the groups of PA and essential hypertension (EH) by confirmatory tests. We performed separate correlation analyses of age and DRC, PAC, and ARR, the patients were then further subdivided into four age groups: < 40, 40-49, 50-59, and ≥ 60 years old. Receiver operating characteristic curve and area under the curve (AUC) were used to determine age-specific ARR cutoff values for screening PA. We screened a total of 478 patients, comprising 255 diagnosed with PA (53.35%) and 176 with EH (36.82%). In patients with EH, PAC and DRC decreased with increasing age (p < 0.001, r = -0.34; p < 0.001, r = -0.28), whereas ARR increased with age (p = 0.002, r = 0.22). However, in patients with PA, DRC, PAC, and ARR did not show significant association with age (p = 0.40, 0.54, 0.33). The cutoff values of ARR for screening PA in four groups were 17.49, 20.79, 21.01, and 18.22. The optimal ARR cutoff was 22.52 in the all-ages, with an AUC of 0.948 (95% CI: 0.929, 0.966), sensitivity of 89.4%, and specificity of 85.2%. There was no significant correlation between age and DRC or PAC in patients with PA. Compared to the consensus-recommended cutoff of 37 (pg / mL)/(μIU/mL), a lower ARR cutoff may be more appropriate for screening PA.

Alterations of White Matter Microstructure in Primary Aldosteronism Patients With Normal Cognitive Functioning Using Diffusion Tensor Imaging

Objective

To detect white matter microstructural alterations in patients with primary aldosteronism (PA) with normal cognitive function using diffusion tensor imaging (DTI).

Methods

This study included PA patients and normotensive healthy controls (HCs). MRI (T1-weighted) and DTI data were collected for all participants. Using the Johns Hopkins University white matter fiber tractography template, we calculated the values of fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD), and mean diffusivity (MD).

Results

Compared to the HC group, the PA group showed significant increases in AD in cingulum bundle cingulate part (CgC.R), forceps minor (FMi), bilateral inferior fronto-occipital fasciculi (IFO), and right temporo-superior longitudinal fasciculus (tSLF.R); RD in left IFO (IFO.L) and right superior longitudinal fasciculus (SLF.R); and MD in FMi, IFO.L, right IFO (IFO.R) and SLF.R.

Conclusion

Compensatory white matter alterations occur in PA patients before cognitive impairment. These alterations may serve as early imaging biomarkers for PA-related brain function impairment, highlighting the importance of advanced neuroimaging for early diagnosis and intervention.

The relationship between tissue inhibitor of metalloproteinases-1 and KCNJ5 mutation in aldosterone-producing adenoma patients

KCNJ5 somatic mutations in aldosterone-producing adenoma (APA) are linked to higher left ventricular mass index (LVMI) and worse diastolic function. We previously identified an association between plasma tissue inhibitor of metalloproteinases-1 (TIMP-1) and an aldosterone-induced increase in LVMI and diastolic dysfunction. This study aimed to investigate the association between the presence of KCNJ5 somatic mutation and plasma TIMP-1 in APA patients. We enrolled 60 APA patients undergoing adrenalectomy, including 30 with KCNJ5 mutations (KCNJ5(+)) and 30 without (KCNJ5(-)). Clinical characteristics, echocardiographic data (including LVMI, inappropriately excessive LVMI (ieLVMI), and diastolic function) and plasma TIMP-1 levels were measured before surgery and 1 year postoperatively. The results showed that the KCNJ5(+) group had higher plasma TIMP-1 levels (P = 0.004) compared to the KCNJ5(-) group. The correlation between the KCNJ5 mutations and TIMP-1 levels remained significant after multiple regression analysis. To detect KCNJ5 mutations, receiver operating characteristic curve analysis showed TIMP-1 had the best area under the curve (AUC) value among various clinical parameters (AUC = 0.682, 95% confidence interval = 0.549-0.796, P = 0.008). Post-adrenalectomy, only the KCNJ5(+) group showed significant decrease in LVMI (P = 0.001) and log-transformed TIMP-1 levels (P = 0.035). Changes in ieLVMI before and after surgery were consistently correlated with changes in TIMP-1 levels in multivariable regression analysis. In conclusion, KCNJ5 somatic mutations in APA are associated with higher plasma TIMP-1 levels. In addition, TIMP-1 is an effective biomarker for detecting the presence of KCNJ5 mutations in APA patients.

Preoperative predictive indicators for resolution of hypertension in patients with unilateral primary aldosteronism: development of a nomogram model

BACKGROUND

Primary aldosteronism (PA) is the leading surgically treatable cause of hypertension, with adrenalectomy as the definitive treatment for unilateral PA (UPA). However, some patients have persistent hypertension after surgery. This study aims to identify preoperative factors affecting surgical outcomes and develop a predictive model for postoperative hypertension resolution.

METHODS

We reviewed and analyzed the medical records of 206 patients who underwent unilateral adrenalectomy for UPA at Qilu Hospital of Shandong University (2011-2022). As a training cohort, the data of the 166 patients from 2013 to 2022 was analyzed using univariate and multivariate logistic regression to explore the relationship between preoperative clinical and biochemical data and postoperative BP normalization. The remaining 40 patients from 2011 to 2012 were used as a validation cohort. A predictive model of the nomogram was constructed utilizing significant variables through multivariate logistic regression analysis. The model's effectiveness was evaluated using receiver operating characteristic (ROC) curves, decision curve analysis (DCA), and calibration curves and compared with previous prediction models using the Delong test.

RESULTS

In the training cohort of 166 patients, 78 (46.9%) achieved postoperative normotension without medication, while 88 (53.1%) required ongoing antihypertensive treatment. Multifactorial analysis identified age, number of antihypertensive medications, preoperative maximum systolic blood pressure (SBP), left ventricular ejection fraction (LVEF), serum creatinine (Cr) levels, and a history of hypokalemia as independent predictors of postoperative BP normalization. Calibration curves showed excellent agreement between predicted and actual outcomes, and DCA indicated that clinical interventions based on this model are beneficial at various risk thresholds. Comparison with previous models showed our model outperformed the Aldosteronoma Resolution Score (ARS) in the Asian population and was comparable to the Morisaki score.

CONCLUSION

A predictive model developed with variables including age, number of anti-hypertensive medications, preoperative maximum SBP, LVEF, serum Cr levels, and history of hypokalemia effectively predicts therapeutic outcomes following unilateral adrenalectomy for UPA patients.

The Effects of Aldosterone on Hypertension-Associated Kidney Injury in a Tg-hAS Mouse Model

Hypertension remains a global health challenge due to its high prevalence and association with premature morbidity and mortality. Aldosterone, a mineralocorticoid hormone, and its receptor, the mineralocorticoid receptor (MR), are highly implicated in hypertension pathogenesis. Aldosterone synthase is the sole enzyme responsible for producing aldosterone in humans. We established transgenic mice carrying the human aldosterone synthase gene (cyp11B2) and showed dramatically increased levels of aldosterone in female hemizygotes. High-salt diets persistently increased blood pressure in these mice, and salt-induced hypertension was significantly ameliorated by reducing aldosterone levels via an aldosterone synthase inhibitor or blocking MR via an MR inhibitor. Since both hypertension and hyperaldosteronism specifically induce chronic kidney disease, in this model, we demonstrated that chronic high-salt diets induced hypertension in this mouse line and resulted in kidney inflammation and injury. Both the aldosterone synthase inhibitor and the MR antagonist markedly blocked high-salt-diet-mediated kidney injury. Thus, this transgenic mouse line can be used to study the pathogenic mechanisms underlying aldosterone and its receptor and to screen therapeutic compounds for aldosterone-mediated hypertension and related complications, such as kidney disease, in humans.

Aldosterone in the brain and cognition: knowns and unknowns

Mineralocorticoid receptors are expressed in several structures of the central nervous system, and aldosterone levels can be measured in the brain, although in smaller amounts than in plasma. Nevertheless, these amounts appear to be sufficient to elicit substantial clinical effects. Primary aldosteronism, characterized by high levels of plasma aldosterone, is one of the most common causes of secondary hypertension. In this context, high aldosterone levels may have both indirect and direct effects on the brain with a negative impact on several cerebral functions. Thus, chronic aldosterone excess has been associated with symptoms of anxiety and depression - two clinical entities themselves associated with cognitive deficits. Today, there is an increasing number of reports on the influence of aldosterone on the brain, but there is also a significant amount of uncertainty, such as the role of high aldosterone levels on cognitive functions and decline independently of blood pressure. In this mini review, we discuss the known and unknowns of the impact of aldosterone on the brain putting emphasis on cognitive functions.

Executive summary of the Spanish consensus for the diagnosis, management, and follow-up of primary hyperaldosteronism

Primary hyperaldosteronism (PH) is the most common cause of secondary hypertension (HTN) and is associated with a higher cardiometabolic risk than essential HTN. Nevertheless, PH remains clearly underdiagnosed. An early diagnosis and adequate treatment of this disease are essential to reduce the cardiometabolic morbimortality associated with aldosterone excess. PH follow-up is equally essential; however, there is little consensus on how it should be performed, being a topic rarely mentioned by the different clinical practice guidelines. The aim of this executive summary is to summarize the recommendations made in the Spanish consensus of PH for the diagnosis, management, and follow-up of these patients. The Spanish consensus was reached from a multidisciplinary perspective through a nominal group consensus approach by experts from the Spanish Society of Endocrinology and Nutrition (SEEN), the Spanish Society of Cardiology (SEC), the Spanish Society of Nephrology (SEN), the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Radiology (SERAM), the Spanish Society of Vascular and Interventional Radiology (SERVEI), the Spanish Society of Laboratory Medicine (SEQC(ML)), the Spanish Society of Anatomic-Pathology (EAP), and the Spanish Association of Surgeons (AEC).

Effects of different treatment modalities on cardiovascular disease in ARR-positive hypertensive patients

Data on the prognosis of clinically undiagnosed hypertensive patients who are aldosterone-to-renin ratio (ARR) positive are still scarce. Therefore, we investigated the clinical characteristics of clinically undiagnosed hypertensive patients who were ARR-positive and the influence of their different treatments on the occurrence and development of complications. A total of 285 hypertensive patients data with ARR ≥ 3.8 in the Second People's Hospital of Huai'an from January 2019 to December 2021 were collected, and 135 undiagnosed hypertensive patients were ultimately included in the analysis. According to their treatment strategy in various clinical departments, 135 patients were divided into the operation, spironolactone and control groups. Then, the clinical characteristics and the occurrence and development of complications in the three groups were compared. The results suggested that: (1) Only 34 (11.9%) of 285 hypertensive patients with ARR ≥ 3.8 were clearly diagnosed with Primary aldosteronism (PA) through functional tests, and the blood pressure (BP) compliance rate was only 50.30% during follow-up. (2) Based on exclusion criteria, 135 undiagnosed hypertensive patients were eventually included in the analysis. Patients in the surgery group had lower blood potassium levels and higher aldosterone levels than those in the other two groups, and their risk of new cerebrovascular complications was lower than that of the patients in the spironolactone group. (3) The risk of new cerebrovascular complications in the spironolactone group was 9.520 times higher than that of the control group, and this risk mainly occurred in patients with ARR values of 3.8-5.7. On the whole, surgery remains a good option for hypertensive patients with severe hyperaldosteronism and hypokalemia and those unable to undergo confirmatory tests; however, spironolactone therapy in patients with clinically undiagnosed hypertension, especially those with 3.8 ≤ ARR < 5.7, confered a higher risk of new cerebrovascular complications.

Screening and diagnosis of primary aldosteronism. Consensus document of all the Spanish Societies involved in the management of primary aldosteronism

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).

Diagnosis and management of resistant hypertension

Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.

Comparisons of risk factors for post-treatment renal dysfunction between the two major subtypes of primary aldosteronism

OBJECTIVE

Aldosterone-producing adenoma (APA) and bilateral idiopathic hyperaldosteronism (IHA) are the most common subtypes of primary aldosteronism (PA), and the PA subtype dictates the treatment options. This study aimed to identify predictors of declined estimated glomerular filtration rate (eGFR) following each treatment in patients with APA and IHA.

METHODS

We retrospectively investigated 45 patients with APA who had undergone adrenalectomy (ADX) and 37 patients with IHA who had received treatment with a mineralocorticoid receptor antagonist (MRA) to identify pre-treatment risk factors for eGFR decline during the post-treatment follow-up period.

RESULTS

Patients with APA who underwent ADX exhibited higher eGFR declines than patients with IHA treated with MRA at the 6-month post-treatment evaluation point. A high preoperative plasma aldosterone concentration (PAC) in patients with APA and a high body mass index (BMI) in patients with IHA were identified as independent predictors of higher eGFR decline at 6 months post-treatment (β=0.42 and β=0.36, respectively). In patients with APA, the cutoff PAC to best predict a 20% decrease in eGFR following ADX, as determined by receiver operating characteristic analysis, was 524 pg/mL. In patients with IHA, the cutoff BMI to best predict a 10% decrease in eGFR following MRA administration was 25.3 kg/m2. In addition, lower preoperative flow-mediated vasodilation was associated with eGFR decline after ADX in patients with APA.

CONCLUSIONS

Greater attention should be given to the above-mentioned risk factors to prevent renal impairment following each treatment in patients with both APA and IHA.

Reversal of arterial stiffness in medically and surgically treated unilateral primary aldosteronism

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.

Comparative study of stretched-exponential and kurtosis models of diffusion-weighted imaging in renal assessment to distinguish patients with primary aldosteronism from healthy controls

PURPOSE

To compare the ability of diffusion parameters obtained by stretched-exponential and kurtosis models of diffusion-weighted imaging (DWI) to distinguish between patients with primary aldosteronism (PA) and healthy controls (HCs) in renal assessment.

MATERIALS AND METHODS

A total of 44 participants (22 patients and 22 HCs) underwent renal MRI with an 11 b-value DWI sequence and a 3 b-value diffusion kurtosis imaging (DKI) sequence from June 2021 to April 2022. Binary logistic regression was used to construct regression models combining different diffusion parameters. Receiver-operating characteristic (ROC) curve analysis and comparisons were used to evaluate the ability of single diffusion parameters and combined diffusion models to distinguish between the two groups.

RESULTS

A total of six diffusion parameters (including the cortical anomalous exponent term [α_Cortex], medullary fractional anisotropy [FA_Medulla], cortical FA [FA_Cortex], cortical axial diffusivity [Da_Cortex], medullary mean diffusivity [MD_Medulla] and medullary radial diffusivity [Dr_Medulla]) were included, and 10 regression models were studied. The area under the curve (AUC) of Dr_Medulla was 0.855, comparable to that of FA_Cortex and FA_Medulla and significantly higher than that of α_Cortex, Da_Cortex and MD_Medulla. The AUC of the Model_all parameters was 0.967, comparable to that of Model_FA (0.946) and Model_DKI (0.966) and significantly higher than that of the other models. The sensitivity and specificity of Model_all parameters were 87.2% and 95%, respectively.

CONCLUSION

The Model_all parameters, Model_FA and Model_DKI were valid for differentiating between PA patients and HCs with similar differentiation efficacy and were superior to single diffusion parameters and other models.

A controlled trial of percutaneous adrenal arterial embolization for hypertension in patients with idiopathic hyperaldosteronism

Our prior study has suggested that percutaneous superselective adrenal arterial embolization (SAAE) with ethanol reduces blood pressure in patients with primary aldosteronism. This study aimed to compare the efficacy of SAAE with mineralocorticoid receptor antagonists (MRA) in treating patients with idiopathic hyperaldosteronism. In this prospective, randomized, controlled trial, we randomly assigned patients with idiopathic hyperaldosteronism in a 1:1 ratio to undergo SAAE (n = 29) or receive MRA (n = 30) treatment. The primary endpoint was the change in mean 24-hour ambulatory systolic blood pressure at 6 months. The secondary endpoints included changes in office blood pressure, home blood pressure, correction of aldosterone-to-renin ratio, and adverse events at 6 months. The mean change in 24-h ambulatory systolic blood pressure from baseline to 6-month follow-up was significantly different between the two groups (-8.4 mmHg; 95% confidence interval, -15.2 to -2.1 mmHg; P < 0.01). Office, home, and ambulatory blood pressure reduction at 6 months was more pronounced in the SAAE group than the MRA group (all P < 0.05). Aldosterone-to-renin ratio was lower in the SAAE group than the MRA group at 1 and 3 months (both P < 0.01), while it had no difference between the two groups at 6 months. None of the patients experienced serious adverse events in the perioperative and 6-month follow-up periods. SAAE, as a hormonal debulking procedure, is superior to MRA in blood pressure control and correction of biochemical abnormalities in patients with idiopathic hyperaldosteronism.

Diagnostic Delay and Disease Burden in Primary Aldosteronism: An International Patient Survey

BACKGROUND

Primary aldosteronism (PA) is a common but underdiagnosed cause of hypertension. Many patients experience preventable end-organ injury due to delayed or missed diagnosis but data on the experience of patients are limited.

METHODS

We evaluated the lived experience of PA and determines factors associated with diagnostic delay through an international anonymous online cross-sectional survey, codesigned by researchers and PA consumers. We distributed the survey through academic medical centers, Amazon Mechanical Turk, Twitter, PA patient advocacy groups, and hypertension support groups on Facebook between March 21 and June 5, 2022.

RESULTS

Of 684 eligible respondents, 66.5% were women. Diagnostic delay (defined as ≥5 years between the diagnosis of hypertension and PA) was reported in 35.6%. Delay was more likely in women than in men (odds ratio, 1.55 [95% CI, 1.10-2.20]) and respondents with ≥3 comorbidities versus none (odds ratio, 1.77 [95% CI, 1.05-3.02]), ≥10 symptoms versus none (odds ratio, 2.73 [95% CI, 1.74-4.44]), and on ≥4 antihypertensive medications versus none (odds ratio, 18.23 [95% CI, 6.24-77.72]). Three-quarters of patients (74.4%) experienced reduced symptom burden following targeted PA treatment. Quality of life improved in 62.3% of patients, and greater improvement was associated with being a woman (odds ratio, 1.42, [95% CI, 1.02-1.97]), receiving adrenalectomy (odds ratio, 2.36 [95% CI, 1.67-3.35]), and taking fewer antihypertensive medications following diagnosis (odds ratio, 5.28 [95% CI, 3.55-7.90]).

CONCLUSIONS

One-third of patients with PA experienced prolonged diagnostic delays. Targeted treatment led to reduced symptom burden and improved quality of life. Gender differences in diagnostic delay and symptom burden are prominent. These findings suggest that routine screening for PA at the onset of hypertension may reduce diagnostic delay and facilitate timely diagnosis.

Central diastolic blood pressure, plasma aldosterone and uric acid are associated with microalbuminuria in essential hypertension: a case-control study

OBJECTIVE

To study the development of microalbuminuria (MAU) in essential hypertension (EHT), we investigated the association of MAU with central blood pressure (CBP), direct renin concentration (DRC), plasma aldosterone (PA), and uric acid (UA).

METHOD

We determined 24 h-urinary albumin excretion (24 h-UAE) in patients with EHT who were hospitalized at TEDA International Cardiovascular Hospital from June 2020 to May 2022. We defined MAU as 24 h-UAE in the range of 30 mg/24 h to 300 mg/24 h. Univariate and multivariate analyses were conducted to determine the associations of MAU with CBP, DRC, PA, and UA in EHT, considering demographic and clinical information. We also plotted receiver operating characteristic curves (ROCs) for predicting MAU using these results.

RESULTS

More than a quarter of patients (26.5%, 107/404, 95% CI: 22.2-31.1%) were diagnosed with MAU in EHT. A higher body mass index (BMI), longer duration of hypertension, and higher severity were associated with MAU. Also, nearly 10% more creatinine levels were recorded in the MAU group than in the control group (69.5 ± 18.7 µmol/L vs. 64.8 ± 12.5 µmol/L, P = 0.004). The increase was also observed for PA (15.5, 9.7-20.6 ng/dL vs. 12.3, 9.0-17.3 ng/dL, P = 0.024) and UA (419.8 ± 105.6 µmol/L vs. 375.1 ± 89.5 µmol/L, P < 0.001) in the MAU group compared to that in the control group. Several variables were associated with MAU, including central diastolic blood pressure (CDBP) (OR = 1.017, 95% CI: 1.002-1.032, P = 0.027), PA (OR = 1.043, 95% CI: 1.009-1.078, P = 0.012) and UA (OR = 1.005, 95% CI: 1.002-1.008, P < 0.001). For MAU prediction, the area under the curve (AUC) was 0.709 (95% CI: 0.662-0.753; P < 0.001) when CDBP, PA, and UA were used in combination, and the optimal probability of the cut-off value was 0.337.

CONCLUSION

We found that CDBP, PA, and UA, used for MAU prediction, might be associated with its development during EHT.

Association between Use of Spironolactone and Risk of Stroke in Hypertensive Patients: A Cohort Study

Objective: to investigate the relationship between the use of spironolactone and the risk of stroke in hypertensive patients. Methods: a total of 2464 spironolactone users and 12,928 non-users were identified (unmatched original cohort), and 1:1 matched pairs of 2461 spironolactone users and 2461 non-users based on propensity scores were created (propensity-score-matched cohort). Results: In the unmatched original cohort, the unadjusted analysis showed that the use of spironolactone was associated with a lower risk of total stroke (HR, 0.71; 95% CI, 0.61−0.84; p < 0.001), which was sustained in the adjusted analysis. According to stroke type, the association was with ischemic strokes (propensity-score-adjusted HR, 0.71; 95% CI, 0.59−0.85; p < 0.001) and hemorrhagic ones (propensity-score-adjusted HR, 0.63; 95% CI, 0.45−0.88; p = 0.008). Similar results were shown in the propensity-score-matched cohort. The results of the subgroup and sensitivity analyses were consistent with those of the primary analysis. The dose−response analysis demonstrated a dose-dependent association of spironolactone with a lower risk of stroke in hypertensive patients. Conclusions: The use of spironolactone was associated with a significantly lower risk of stroke events in hypertensive patients. Further research, including prospective randomized clinical trials, is needed to validate our findings.

Stroke Risks in Primary Aldosteronism with Different Treatments: A Systematic Review and Meta-Analysis

Background: Primary aldosteronism (PA) is a common cause of secondary hypertension and confers a higher risk of stroke. The treatment strategies of PA mainly include medical and adrenalectomy treatment, while there is still no solid conclusion on how these two different treatment strategies mitigate the detrimental effect of PA on stroke. Methods: PubMed, Embase, and Cochrane Library were searched for studies comparing stroke events in patients with PA receiving medical treatment versus adrenalectomy treatment published up to 19 March 2022, including patients with essential hypertension as a control group. We used either fixed or random effect models according to the heterogeneities. Sensitivity analysis was conducted by deleting each study one at a time. Results: We reviewed 201 articles, and three studies met the final criteria, including 3244 PA patients with medical treatment, 1611 PA patients with adrenalectomy treatment, and 20,568 EH patients. Patients with PA post adrenalectomy were observed with a significantly decreased risk of stroke compared to patients receiving medical treatment (OR: 0.57, 95% CI: 0.35−0.93, p = 0.03), and with no difference when compared to patients with essential hypertension. Patients with PA receiving medical treatment were still observed with higher stroke risks (OR: 1.88, 95% CI: 1.68−2.11, p < 0.00001) than patients with essential hypertension. Conclusion: PA is a critical modifiable risk factor for stroke. Adrenalectomy has a superior performance in the mitigation of stroke risks among patients with PA.

Differences in Glycemic Abnormalities Between Primary Aldosteronism and Essential Hypertension: A Systematic Review and Meta-Analysis

Background

The relationship of glycemic abnormalities between primary aldosteronism (PA) patients and essential hypertension (EH) patients is still debatable. This meta-analysis aimed to explore differences in the prevalence of glycemic abnormalities and levels of abnormal glucose metabolism in PA and EH patients.

Methods

A search was performed using PubMed, Scopus, Cochrane and Web of Science databases from their inception through January 2022. Inclusion criteria for this study were 1) observational studies which contained specific data of interest, 2) studies including data which compared adult PA and EH patients and 3) studies which used appropriate methods to diagnose PA. Risk ratio (RR) or standardized mean difference (SMD) with a 95% confidence interval (95% CI) was calculated.

Results

Twenty-six studies involving 53,186 patients were included in the meta-analysis. Patients with PA demonstrated significantly higher overall incidence of glycemic abnormalities than patients with EH [RR 1.54; 95% CI (1.20,1.98)]. Risk of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in PA patients were higher than in EH patients [RR 1.27; 95%CI (1.08, 1.49) and RR 2.99; 95%CI (1.74, 5.16), respectively]. There was no statistically significant difference of risk between these groups for impaired fasting glucose (IFG) [RR 1.70; 95%CI (0.55, 5.26)]. Moderate heterogeneity was observed in overall glycemic abnormalities outcomes. A high level of heterogeneity was observed for IFG, while the level was low for DM and IGT.

Conclusions

PA patients have a higher risk of glycemic abnormalities than in EH patients. Further study should be conducted to investigate underlying mechanisms of glycemic abnormalities in PA.

Systematic Review Registration

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