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

Abstract

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.

Prevalence of primary aldosteronism in acute stroke or transient ischemic attack: a systematic review and meta-analysis

“…Following title and abstract screening, 32 full text articles remained for screening. Three articles fulfilled eligibility criteria for inclusion ( Figure 1 ) ( 6 , 15 , 16 ).…”

“…Two single center studies, one from Singapore and the other from Japan, were cohort studies of patients admitted with stroke or TIA ( 6 , 15 ). The third, also a single center study undertaken in China, was a cross-sectional study in young adults with stroke or TIA ( 16 ).…”

“…A meta-analysis of 31 studies, including 3838 patients with PA and 9284 patients with essential hypertension found that after a median of 8.8 years from hypertension diagnosis, compared to patients with essential hypertension, patients with PA had an increased risk of stroke with an odds ratio [OR] of 2.58 (95% CI 1.93-3.45) ( 5 ). Furthermore, we now know PA is more prevalent in patients with cardioembolic stroke and atrial fibrillation (AF) ( 6 ). PA is a treatable condition, either with curative surgery in the setting of a unilateral aldosterone producing adenoma or mineralocorticoid receptor antagonists (MRA) for bilateral adrenal disease.…”

Primary Aldosteronism Prevalence – An Unfolding Story

“…[2] Nguyen and colleagues performed PA testing among 300 consecutive patients with hemorrhagic or ischemic stroke and found overt PA in 30% of patients with hypertension and atrial fibrillation, as compared to 11.1% in the subgroup with treatment-resistant hypertension and 13.3% in those with hypertension and hypokalemia. [90] Another observational study found that overt PA was highly prevalent (42.5%) in participants with atrial fibrillation and no other identifiable causes of arrhythmia, such as structural heart defect or coronary artery disease, suggesting that overt PA might have led to atrial fibrillation in these patients. [91] Current guidelines do not yet endorse screening for PA in patients with atrial fibrillation.…”

“…Atrial fibrillation has emerged as one of the cardiovascular complications associated with PA. A meta-analysis found atrial fibrillation to be 3.52 times more likely in patients with overt PA than in those with primary hypertension [2]. Nguyen and colleagues performed PA testing among 300 consecutive patients with hemorrhagic or ischemic stroke and found overt PA in 30 % of patients with hypertension and atrial fibrillation, compared to 11.1 % in the subgroup with treatment-resistant hypertension and 13.3 % in those with hypertension and hypokalemia [90]. Another observational study found that overt PA was highly prevalent (42.5 %) in participants with atrial fibrillation and no other identifiable causes of arrhythmia, such as structural heart defect or coronary artery disease, suggesting that overt PA might have led to atrial fibrillation in these patients [91].…”