Primary Aldosteronism

HomeHypertensionVol. 77, No. 3Primary Aldosteronism Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyRedditDiggEmail Jump toFree AccessEditorialPDF/EPUBPrimary AldosteronismThree Strikes and Out John W. Funder FunderJohn Correspondence to: Funder, Hudson Institute of Medical Research Monash University, Clayton 3800, Victoria, Australia. Email E-mail Address: [email protected] https://orcid.org/0000-0001-7733-7005 From the Clayton, Search for more papers by this author Originally published10 Feb 2021https://doi.org/10.1161/HYPERTENSIONAHA.120.16585Hypertension. 2021;77:900–903This article is a commentary on followingIntraindividual Variability Aldosterone Concentrations in Primary AldosteronismIn current issue Journal Nicholas Yolamp his colleagues have published entitled “Intraindividual Aldosteronism: Implications Case Detection.”1 When patient referred possible primary aldosteronism, first thing done withdraw 4 6 weeks many/all their antihypertensive medications, if necessary replaced alpha blockers or calcium channel blockers. Subsequently case detection—more colloquially, screening—depends 3 ways plasma aldosterone concentration measured as single morning blood draw. The used numerator so-called renin ratio. combination certain concentration—commonly 15 ng/dL, an ratio 20, 30, sometimes even 40 ng/dL per ng/mL/h—establishes candidate aldosteronism. Finally, patients screening positive are then most circumstances offered any one half dozen confirmatory tests, outcomes which dependent extent suppression concentration.See related article, pp 891–899If you thought that steps investigation aldosteronism disincentive physicians refer (or accede suggestion made) correct. On my reckoning—and many others—fewer than 1% hypertensives ever screened testimony effectiveness disincentives; it also reflects magisterial indifference leaders hypertension community its prevalence. In recent 24 page “2020 International Society Hypertension Global Practice Guidelines”2 total coverage was lines Table 11, 14. Similarly, received just 143 references, like licorice; addressed nonadherence prescribed regimens.In present authors shown, closely curated cohort 51 with resistant hypertension, when such underwent two, up six, draws individual levels ranged from 4.9 those staggering over 50-fold range, 8.2 427 ng/mL/h. Within subjects, coefficient variation 31%, 45%. Almost had at least reading below 31% 2 30% 10 ng/dL.The neatly sum take study—methodology exemplary, data irrefutable—in final sentence perspectives section. “Given high prevalence low rates diagnosis, cardiometabolic morbidity mortality associated untreated disease, these findings suggest recalibration toward permissive criteria, reliance assessment, could improve detection true cases decrease false negative interpretations.” Quite so: but 2, 6, concentrations should we choose guide us? Which multiple assessments, similarly?This might be construed hand-wringing: what needed not squarely facing demonstrated fallibility spot estimating patient’s secretory status; only way can measuring 24-hour urinary excretion aldosterone. Anand Vaidya has been senior telling studies past months. first, “The Unrecognized Prevalence Aldosteronism,”3 game-changer, basis hour collection 1000 subjects suppressed renin, sodium loaded (200–300 meq/day), generous figure 12 mcg/day upper limit normal aldosterone, coauthors found 3- 5-fold higher currently recognized. If cutoff face less enthusiastic were mcg/day, instance 60% patients.That Strike One. Two second press,4 Boston group address question variability measurements before during adrenal venous sampling. Of 340 who sampling, 116 addition average 2.5 hours procedure began. latter group, mean fell 51%, median decline 7.0 ng/dL; quarter beginning sampling <5 ng/dL. triplicate veins (left) 39% (right). confirms extends concentration, completing change: Three.It though come out left field, stretch analogy. A previous study Baudrand et al5 210 normotensives. same take-no-prisoners criteria (sodium loading, above mcg/day), 29 tested aldosteronism; draw used, positive. series laboratory George Piaditis Athens,6,7 crucial role ACTH (adrenocorticotrophic hormone)—long neglected field—as potent episodic elevator demonstrated, suggesting overall ≈50%.Apparently lost mists time Cologne,8 vintage 1980, until very recently garnered 39 citations, roughly commentary. Professor Helber put groups subjects—56 normotensive controls, 100 essential hypertensives, 16 confirmed aldosteronism—on 175 meq diet days, normotensives µg/24/h, predictably far higher. 64 within established 36 above. Patients range challenged spironolactone showed 9 mm Hg fall systolic pressure; pressure 23 response spironolactone. take-home message article’s title “Evidence subgroup nonsuppressible loading”—that is, they really aldosteronism.If so, why does matter? There compelling reasons action. First, under guidelines, categorized negative—as would cited Second, matters because there persuasive evidence that—unless appropriately treated—patients double jeopardy, terms 3-fold cardiovascular risk profile age-, sex-, pressure-matched hypertensives.9 Third—and here I must differ authors—there no country world where capture rate hypertensives; figures reflect selected populations, (Martin Reincke) publications record confessing Germany 0.1%. We recognize increased premature diabetes, obesity, substance abuse, large part ignorant of, rather dismissive appallingly aldosteronism.Where here? need new endocrinologists Clinical Endocrinology Metabolism, internists care providers. providers commonly point contact newly presenting crucially, shown Figure [A], antihypertensives, measurement renin. activity 1 ng/mL 8 mU/L), onto diet, exercise, etc. suppressed, show how best collect urine bring determination µg/day, word about lowering salt intake. between µg/day—possible aldosteronism—onto 25 mg/day check after weeks. shorter, refined potentially practical form assessing trial alone [B].Download figureDownload PowerPointFigure. Steps diagnosis aldosteronism.A, For hypertensives. B, Alternative C, hypertension.Getting get-go produces unmatched results Surgical Outcomes study,10 Hu al China.11 These do yearly check-ups 147 000 thousand 7% existing criteria. All unilateral disease biochemically cured, all clinically surgery; four-fifths bilateral low-dose It may 30 years substantially reduce PA across community, relatively simple baby step—first measure renin—is forward.For already antihypertensives—even 140/90—the short home (50 mg/day) review (Figure [C]). trivial, discontinue; consistently >10 Hg, parse patients. young, pressure, hypokalemic close to—refer specialized center. mature, well controlled medication, continue spironolactone, side effects lower dose add epithelial inhibitors. suggestions, tablets stone, considered, discussed, amended, consensus statement/set guidelines ultimately produced. provided blow order: strikes, batters plate.Sources FundingThis work supported Victorian Government’s Operational Infrastructure Support Program.Disclosures None.FootnotesThe opinions expressed necessarily American Heart Association.For Disclosures, see 903.Correspondence john.[email protected]org.auReferences1. Yozamp N, Hundemer G, Moussa M, Underhill J, Fudim T, Sacks A. Intraindividual aldosteronism: implications detection.Hypertension2021; 77:891–899. doi: 10.1161/HYPERTENSIONAHA.120.16429LinkGoogle Scholar2. Unger Borghi Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A, Schlaich Stergiou GS, Tomaszewski al.. 2020 global practice guidelines.Hypertension. 2020; 75:1334–1357. 10.1161/HYPERTENSIONAHA.120.15026LinkGoogle Scholar3. Brown JM, Siddiqui Calhoun DA, Carey RM, Hopkins PN, Williams GH, unrecognized cross-sectional Study.Ann Intern Med. 173:10–20. 10.7326/M20-0065CrossrefMedlineGoogle Scholar4. arenal [published online November 12, 2020].Am J Hypertens. hpaa151. 10.1093/ajh/hpaa151MedlineGoogle Scholar5. R, Guarda FJ, Fardella CE, Continuum renin-independent normotension.Hypertension. 2017; 69:950–956. 1161/HYPERTENSIONAHA.116.08952LinkGoogle Scholar6. Gouli Kaltsas Tzonou Markou Androulakis II, Ragkou Vamvakidis K, Zografos Kontogeorgos Chrousos GP, High autonomous secretion among hypertension.Eur Clin Invest. 2011; 41:1227–1236. 10.1111/j.1365-2362.2011.02531.xCrossrefMedlineGoogle Scholar7. Sertedaki Marakaki Pappa Papanastasiou L, Fountoulakis S, Zacharoulis Stress-induced hyper-secretion substantial subset hypertension.J Endocrinol Metab. 2015; 100:2857–2864. 10.1210/jc.2015-1268CrossrefMedlineGoogle Scholar8. Wambach Hummerich W, Bonner Meurer KA, Kaufmann Evidence non-suppressible loading.Klin Wochenschr. 1980; 58:439–447. 19.1007/BF01476798CrossrefMedlineGoogle Scholar9. GL, Curhan GC, Wang Cardiometabolic medically treated retrospective study.Lancet Diabetes Endocrinol. 2018; 6:51–59. 10.1016/S2213-8587(17)30367-4CrossrefMedlineGoogle Scholar10. TA, Lenders JWM, Mulatero P, Burrello Rottenkolber Adolf Satoh Amar Quinkler Deinum al.; Surgery Outcome (PASO) investigators. adrenalectomy international outcome measures analysis remission cohort.Lancet 5:689–699. 10.1016/S2213-8587(17)30135-3CrossrefMedlineGoogle Scholar11. Xu Z, Yang Song Y, He Luo Cheng Q, Ma Fuller PJ, china detected Am Coll Cardiol. 75:1913–1922. 1016/j.jacc2020.02.052CrossrefMedlineGoogle Scholar Previous Back top Next FiguresReferencesRelatedDetailsRelated articlesIntraindividual AldosteronismNicholas Yozamp, al. Hypertension. 2021;77:891-899 March 2021Vol Issue 3Article InformationMetrics Download: 1,808 © 2021 Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.120.16585PMID: 33566688 publishedFebruary 10, PDF download SubjectsHypertension