Atrial fibrillation as presenting sign of primary aldosteronism: results of the Prospective Appraisal on the Prevalence of Primary Aldosteronism in Hypertensive (PAPPHY) Study

Abstract

Background: Despite hyperaldosteronism being suggested as predisposing to arrhythmias, the relationship between atrial fibrillation and primary aldosteronism remains uncertain. Therefore, we tested the hypothesis that atrial fibrillation is a presentation of primary aldosteronism in hypertensive patients with unexplained atrial fibrillation. Design and methods: The Prospective Appraisal on the Prevalence of Primary Aldosteronism in Hypertensive (PAPPHY) Study recruited consecutive patients with atrial fibrillation and an unambiguous diagnosis of arterial hypertension at three referral centers for hypertension. Results: In a cohort entailing 411 atrial fibrillation patients, we identified 18% (age 61 ± 11 years; 32% women), who showed no known cause of the arrhythmia. A thorough diagnostic work-up allowed us to identify primary aldosteronism in 73 of these patients, i.e. 42% [95% confidence interval (CI) 31.8–53.9]. Subtyping of primary aldosteronism demonstrated that surgically curable forms of primary aldosteronism accounted for 48% of the cases (95% CI 31.9–65.2). The high prevalence of primary aldosteronism was confirmed at sensitivity analyses. Conclusion: These results provided compelling evidence that primary aldosteronism is highly prevalent in hypertensive patients with unexplained atrial fibrillation. Accordingly, they suggest that patients with no identifiable cause of the arrhythmia should be screened for primary aldosteronism to identify those who can be cured or markedly improved with target treatment. Clinical Trial Registration: : https://clinicaltrials.gov, Identifier: NCT01267747.

New-Onset Atrial Fibrillation in Patients With Primary Aldosteronism Receiving Different Treatment Strategies: Systematic Review and Pooled Analysis of Three Studies

“…Excessive aldosterone is a major contributing factor to atrial fibrillation genesis (9,12), as shown in the German Conn's Registry which reported a prevalence rate of atrial fibrillation of 7.1% among 553 PA patients (29). Seccia et al also demonstrated that the PA was highly prevalent in hypertensive patients with unexplained atrial fibrillation in prospective appraisal on the prevalence of primary aldosteronism in hypertensive (PAPPHY) study (30). The MRA also significantly reduced new-onset atrial fibrillation and recurrent atrial fibrillation in general patient population in one recent meta-analysis (31).…”

“…Seccia et al. also demonstrated that the PA was highly prevalent in hypertensive patients with unexplained atrial fibrillation in prospective appraisal on the prevalence of primary aldosteronism in hypertensive (PAPPHY) study ( 30 ). The MRA also significantly reduced new-onset atrial fibrillation and recurrent atrial fibrillation in general patient population in one recent meta-analysis ( 31 ).…”

Unravelling the Genetic Basis of Primary Aldosteronism

“…As a result, aldosterone is ectopically synthesized in the adrenal zona fasciculata under the regulation of ACTH and not under the renin-angiotensin system (RAS) [39]. The diagnosis of FH-I is based on genetic testing for the presence of the chimeric gene, while the treatment involves MRAs or glucocorticoid administration [7].…”

“…However, following the introduction of plasma aldosterone concentration to plasma renin activity ratio (ARR) as a screening test in clinical practice, it became evident that the prevalence of PA is higher than previously thought [3][4][5]. Currently, PA is recognized as the most common cause of secondary hypertension, accounting for 6.1% of hypertensive patients and up to 20% of patients with severe or treatment-resistant hypertension [6,7]. Early identification and treatment of patients with PA is of paramount importance because they have a higher risk of stroke, myocardial infarction, and atrial fibrillation than patients with essential hypertension matched for age, gender, and blood pressure [8].…”

CMR-Verified Myocardial Fibrosis Is Associated With Subclinical Diastolic Dysfunction in Primary Aldosteronism Patients

“…In addition to high blood pressure, increased aldosterone, which has proinflammatory (4) and profibrotic effects (5) on myocardial tissues, is another risk factor for cardiovascular diseases. Previous clinical studies have shown that PA patients are prone to cardiovascular complications (6)(7)(8)(9). PA patients revealed a significantly higher prevalence of coronary artery disease (adjusted OR, 1.9), nonfatal myocardial infarction (adjusted OR, 2.6), heart failure (adjusted OR, 2.9), and atrial fibrillation (adjusted OR, 5.0) than essential hypertension (EH) patients (6).…”