Primary aldosteronism in young adults with acute stroke: Prevalence and clinical characteristics

Tang, Ziwei; Chen, Haiyan; He, Wenwen; Ma, Linqiang; Song, Ying; Mei, Mei; Luo, Ting; Du, Zhenggui; Hu, Jinbo; Cheng, Qingfeng; Wang, Zhihong; Li, Qifu

doi:10.1016/j.jns.2020.116774

Cited by 8 publications

(16 citation statements)

References 20 publications

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“…Although earlier studies found both surgical and medical therapy equally effective, more recent data suggest that surgical treatment leads to better outcomes ( 12 , 13 ). None of our patients underwent subtype testing with adrenal vein sampling and surgery, similar to previous studies ( 29 , 31 ), due to poor functional status or comorbidities in the patients. This emphasizes the importance of early diagnosis of PA, which unfortunately remains suboptimal, with less than 1% of all patients at risk of PA being screened ( 32 ).…”

Section: Discussionmentioning

confidence: 84%

Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation

Nguyen

Mamauag

et al. 2022

Front. Endocrinol.

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BackgroundPrimary aldosteronism (PA) is the most common cause of secondary hypertension, and patients are at an increased risk of atrial fibrillation (AF) and stroke. We assessed the prevalence of PA in patients with recent stroke.MethodsWe recruited 300 patients admitted to an acute stroke unit with diagnosis of cerebrovascular accident (haemorrhagic/ischaemic) or transient ischaemic attack. Three months post-stroke, plasma renin and aldosterone were measured. Patients with an elevated aldosterone–renin ratio proceeded to the confirmatory saline loading test.ResultsTwenty-six of 192 (14%) patients had an elevated aldosterone–renin ratio. Three of 14 patients who proceeded to saline loading were confirmed with PA (post-saline aldosterone >138 pmol/l). Another three patients were classified as confirmed/likely PA based on the markedly elevated aldosterone–renin ratio and clinical characteristics. The overall prevalence of PA amongst stroke patients with hypertension was 4.0% (95% confidence interval (CI): 0.9%–7.1%). Prevalence of PA was higher amongst patients with cardioembolic stroke, 11% (95% CI: 1.3%–33%), resistant hypertension, 11% (95% CI: 0.3%–48%), and hypertension and AF, 30% (95%CI: 6.7%–65%). If only young patients or those with hypokalaemia were screened for PA, half of our patients with PA would not have been diagnosed. Our decision tree identified that stroke patients with AF and diastolic blood pressure ≥83mmHg were most likely to have PA.ConclusionWe found that amongst hypertensive patients with stroke, PA was more prevalent in those with AF, or cardioembolic stroke. Screening for PA should be considered for all patients with stroke.

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Section: Discussionmentioning

confidence: 84%

Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation

Nguyen

Mamauag

et al. 2022

Front. Endocrinol.

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“…The study found that high ARR, or relative aldosterone excess, was a predictor of stroke in conditions of high sodium intake. In recent years, Tang et al [ 24 ] conducted a survey of the prevalence and clinical characteristics of PA in 116 young adults with acute stroke, and found that the prevalence of PA was at least 12.9% among adults with stroke under 45 years old. Among young patients with a history of hypertension and stroke, the prevalence of PA was 21.2%, which was far higher than the general population and stubborn hypertension according to previous reports.…”

Section: Discussionmentioning

confidence: 99%

Screening for unilateral aldosteronism should be combined with the maximum systolic blood pressure, history of stroke and typical nodules

et al. 2022

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To determine factors associated with lateralization in primary aldosteronism (PA). The clinical data for PA patients hospitalized at the First Affiliated Hospital of Guangxi Medical University from October 2016 to March 2021 were included in this study. They were classified according to results derived from computed tomography (CT): bilaterally normal nodules (no typical nodules were found in either adrenal glands, only changes in unilateral adrenal hyperplasia thickening or bilateral adrenal hyperplasia thickening), unilateral nodules (typical nodule appears in unilateral adrenal gland, and there are no abnormalities in the contralateral adrenal gland or only thickening of unilateral adrenal hyperplasia) and bilateral nodules (typical nodule like changes in bilateral adrenal glands). Multivariate logistic regression and receiver operating characteristic (ROC) were used to analyze the factors associated with lateralization of PA and consistencies between adrenal CT images and adrenal venous sampling (AVS) results. A total of 269 patients with PA were recruited, with an average age of 46 years and 112 cases had typical nodules. Results from CT scans revealed that there were 49 bilateral normal cases, 177 cases were unilateral abnormal and 43 cases were bilateral abnormal. In all of the PA patients, multifactorial logistic regression analysis showed that the maximum systolic blood pressure (OR = 1.03, P < .001), history of stroke (OR = 2.61, P = .028), and typical nodules (OR = 1.9, P = .017) were all relevant factors in unilateral primary aldosteronism (UPA). In the unilateral nodule group, multivariate logistic regression analysis suggested that maximum systolic blood pressure (OR = 1.03, P < .001) and typical nodules (OR = 2.37, P = .008) were the related factors for UPA. However, the consistency between adrenal CT and AVS was only 40.68%, while maximum systolic blood pressure (OR = 1.02, P < .001) and plasma aldosterone renin ratio (OR = 1.001, P = .027) were the relevant consistent factors between AVS and CT results. Maximum systolic blood pressure, typical nodules, and history of stroke are important factors to consider when screening for UPA. It is recommended to combine medical history and imaging findings when looking at different subgroups before a clinical decision is made. Patients with PA in the absence of lesions or bilateral lesions on CT should be diagnosed by AVS as far as possible.Abbreviations: ARR = plasma aldosterone renin ratio, AUC = area under the curve, AVS = adrenal venous sampling, BMI = body mass index, BPA = bilateral primary aldosteronism, Ccr = creatinine clearance rate, CCT = Captopril Challenge test, CT = computed tomography, GFR = glomerular filtration rate, LVMI = left ventricular mass index, PA = primary aldosteronism, PAC = plasma aldosterone concentration, PRC = plasma renin concentration, ROC = receiver operating characteristic, SD = standard deviation, SIT = Saline infusion test, UPA = unilateral primary aldosteronism, ZG = glomerular zone.

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“…52 A recent Chinese study identified primary aldosteronism in 12.7% of 116 young adults (<45 years old) who had been admitted for TIA or stroke (hemorrhagic or ischemic). 48 The estimated prevalence was even higher at 21.2% in those with a concurrent history of hypertension. These studies demonstrate that the prevalence of primary aldosteronism is not low among patients with acute stroke, at least in the Asian population, and that testing for primary aldosteronism in suspected cases should be performed (Table 1).…”

Section: Primary Aldosteronism In Secondary Hypertension and Strokementioning

confidence: 95%

“…47 The prevalence of primary aldosteronism increases with advancing stages of hypertension. 48 A cross-sectional study of 1846 patients in the United States evaluated hormonal mechanisms in normotensive individuals and those with hypertension from stage 1 to resistant hypertension. 5 Every BP category from normotension to resistant hypertension displayed a continuum of renin independent aldosterone production.…”

Section: Primary Aldosteronism In Secondary Hypertension and Stroke P...mentioning

confidence: 99%

Hypertension Management in Stroke Prevention

McCarthy

Yang

Clissold

et al. 2021

Stroke

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Primary aldosteronism confers a higher risk of stroke, atrial fibrillation, and cardiovascular disease than blood pressure matched essential hypertension. It is the most common endocrine cause of secondary hypertension with prevalence estimates of up to 13% in primary care and 30% in referral centers around the world. Unlike essential hypertension, primary aldosteronism has targeted medical treatment and potentially curative surgical solutions which can ameliorate the associated cardiovascular risks. This narrative review highlights an evidence gap in the optimal diagnosis and targeted treatment of primary aldosteronism in secondary stroke prevention. Over half of the patients suffering a stroke have blood pressure in the hypertensive range and less than a third achieve optimal blood pressure control. There are no guideline recommendations to test for primary aldosteronism in these patients, although up to 30% of patients with resistant hypertension may have this disease. The accurate diagnosis of primary aldosteronism could significantly improve blood pressure, simplify the medication regimen and reduce the overall cardiovascular risk in these patients. The challenges associated with screening for primary aldosteronism following stroke may be overcome by novel blood tests which are less affected by antihypertensive medications routinely used in stroke care. Approximately one-quarter of all strokes occur in patients who have previously had a stroke. Modifying hypertension, the leading modifiable risk factor, would, therefore, have significant public health implications. As clinicians, we must increase our awareness of primary aldosteronism in patients with stroke, particularly in those with resistant hypertension, to enable targeted therapy and reduce the risk of stroke recurrence.

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Primary aldosteronism in young adults with acute stroke: Prevalence and clinical characteristics

Cited by 8 publications

References 20 publications

Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation

Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation

Screening for unilateral aldosteronism should be combined with the maximum systolic blood pressure, history of stroke and typical nodules

Hypertension Management in Stroke Prevention

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