Drug-resistant hypertension in primary aldosteronism patients undergoing adrenal vein sampling: the AVIS-2-RH study

Abstract

Aims We aimed at determining the rate of drug-resistant arterial hypertension in patients with an unambiguous diagnosis of primary aldosteronism (PA). Moreover, we sought for investigating the diagnostic performance of adrenal vein sampling (AVS), and the effect of adrenalectomy on blood pressure (BP) and prior treatment resistance in PA patients subtyped by AVS in major referral centres. Methods and results The Adrenal Vein Sampling International Study-2 (AVIS-2) was a multicentre international study that recruited consecutive PA patients submitted to AVS, according to current guidelines, during 15 years. The patients were over 18 years old with arterial hypertension and had an unambiguous diagnosis of PA. The rate of resistant hypertension was assessed at baseline and after adrenalectomy using the American Heart Association (AHA) 2018 definition. Information on presence or absence of resistant hypertension was available in 89% of the 1625 enrolled PA patients. Based on the AHA 2018 criteria, resistant hypertension was found in 20% of patients, of which about two-thirds (14%) were men and one-third (6%) women (χ2 = 17.1, P < 1*10−4) with a higher rate of RH in men than in women (23% vs. 15% P < 1*10−4). Of the 292 patients with resistant hypertension, 98 (34%) underwent unilateral AVS-guided adrenalectomy, which resolved BP resistance to antihypertensive treatment in all. Conclusions (i) Resistant hypertension is a common presentation in patients seeking surgical cure of PA; (ii) AVS is key for the optimal management of patients with PA due to resistant hypertension; and (iii) AVS-guided adrenalectomy allowed resolution of treatment-resistant hypertension.

Identification of risk loci for primary aldosteronism in genome-wide association studies

“…These results suggested an implication for aldosterone and the mineralocorticoid pathway in the pathogenesis of resistant hypertension. In this context it is noteworthy that the prevalence of PA increases to up to 20% in patients with resistant hypertension 34 – 36 and that it was the clinical presentation in 20–50% of the patients with PA submitted to adrenal vein sampling in the AVIS-2 Study 37 .…”

Primary Aldosteronism and Drug Resistant Hypertension: A “Chicken-Egg” Story

“…Clinical data from several studies still underline the importance of this procedure even in the RH patients. In the AVIS-2-RH study, 20% of 1450 patients with unambiguous diagnosis of primary aldosteronism had RH, and, after adrenalectomy, resolution of hypertension was achieved in half of the patients [14]. Lee et al analysed retrospectively 48 PA patients who underwent AVS to evaluate clinical outcomes in relationship with lateralization index and contralateral suppression index: in RH patients with no clear evidence of lateralization at AVS, the rate of complete clinical success after adrenalectomy was superior in those with contralateral suppression compared with those without suppression (3 of 9 vs. 1 of 11).…”

Pathophysiology and histopathology of primary aldosteronism

“…Primary aldosteronism (PA) is the most frequent cause of endocrine hypertension in which plasma aldosterone concentrations are normal or elevated relative to suppressed plasma renin levels [5]. The prevalence of PA is around 5% in patients with hypertension in primary care [6,7], 10% in hypertension referral centers [8], and up to 20% in patients with resistant hypertension [9]. PA is however underdiagnosed [10,11] and the true prevalence may be considerably higher than generally contended [12].…”