Management of hypertension in primary aldosteronism

Abstract

Hypertension causes significant morbidity and mortality worldwide, owing to its deleterious effects on the cardiovascular and renal systems. Primary hyperaldosteronism (PA) is the most common cause of reversible hypertension, affecting 5%-18% of adults with hypertension. PA is estimated to result from bilateral adrenal hyperplasia in two-thirds of patients, and from unilateral aldosterone-secreting adenoma in approximately one-third. Suspected cases are initially screened by measurement of the plasma aldosterone-renin-ratio, and may be confirmed by additional noninvasive tests. Localization of aldostosterone hypersecretion is then determined by computed tomography imaging, and in selective cases with adrenal vein sampling. Solitary adenomas are managed by laparoscopic or robotic resection, while bilateral hyperplasia is treated with mineralocorticoid antagonists. Biochemical cure following adrenalectomy occurs in 99% of patients, and hemodynamic improvement is seen in over 90%, prompting a reduction in quantity of anti-hypertensive medications in most patients. End-organ damage secondary to hypertension and excess aldosterone is significantly improved by both surgical and medical treatment, as manifested by decreased left ventricular hypertrophy, arterial stiffness, and proteinuria, highlighting the importance of proper diagnosis and treatment of primary hyperaldosteronism. Although numerous independent predictors of resolution of hypertension after adrenalectomy for unilateral adenomas have been described, the Aldosteronoma Resolution Score is a validated multifactorial model convenient for use in daily clinical practice.

Keywords: Primary hyperaldosteronism; Hypertension; Adrenalectomy; Aldosteronoma; Treatment

Core tip: Primary hyperaldosteronism is the most common reversible form of secondary hypertension. After appropriate diagnosis and localization studies, adrenalectomy is the procedure of choice for unilateral aldosterone-secreting adenomas, while medical therapy is best for bilateral adrenal hyperplasia. Surgical resection improves or cures biochemical and hemodynamic perturbations in most patients, and halts or reverses many of the deleterious effects of hyperaldosteronism. Predicting which patients will benefit most from adrenalectomy is aided by the Aldosteronoma Resolution Score.