The current epidemic of primary aldosteronism

Abstract

Until recently, primary aldosteronism was considered to be a rare cause of identifiable or secondary hypertension. Over the past 10 years, a steadily growing number of reports have claimed that this condition is much more common, present in 5-40% of all hypertensive patients, which translates into many millions of patients. The primary basis for this current epidemic is the application of a relatively simple screening test, the plasma aldosterone to renin ratio (ARR). Despite growing recognition that the ARR is neither sensitive nor specific, its advocates recommend that it should be a routine procedure in evaluation of all hypertensives. Evidence is provided that this recommendation will lead to massive increases in costs, both in money and in morbidity, while providing benefit to only a very small number of patients who would not be aided by continuation of previous diagnostic protocols.

Prevalence of Primary Aldosteronism among Unselected Hypertensive Patients: A Prospective Study Based on the Use of an Aldosterone/Renin Ratio above 25 as a Screening Test

“…Therefore early detection, diagnosis and management of PA is likely to result in beneficial effects extending beyond improved hypertension control. It has been argued that the use of wider screening strategies might result in significantly increased health expenditure resulting from the costs of performing ARR measurements, confirmatory tests, CT scan and eventual adrenal venous sampling in a greater number of hypertensives (47). However, it should be remembered that the great majority of patients who undergo ARR testing, which per se is relatively inexpensive, will test negative and therefore will be excluded from having to undergo the more expensive confirmatory tests, CT and AVS.…”

Hyperaldosteronism and Hypertension

“…4 Recent observations that many patients with hypertension have evidence of excess aldosterone production, as reflected by an elevated aldosterone/renin ratio, has led to a surge in interest provoked by the 5-to 15-fold increase in the reported frequency of primary aldosteronism reported in the past few years. 5 In a recent report from The Framingham Offspring Study, higher plasma aldosterone concentrations within the physiological range predisposed nonhypertensive participants to the subsequent development of hypertension. 6 Extracellular fluid volume is an important contributor to the pathogenesis of low-renin hypertension and to hypertension in blacks.…”

Long-term re-evaluation of primary aldosteronism after medical treatment reveals high proportion of normal mineralocorticoid secretion

“…Long-acting dihydropyridinic and non-dihydropyridinic calcium-antagonists were permitted when pressure control was poor with a-blockers. It is a shared opinion that dihydropyridinic calcium channel blockers do not significantly affect aldosterone secretion, causing mainly an increase in PRA, which rarely gives false negatives (5,11,12). Furthermore, patients treated with these drugs at reappraisal were almost the same as at diagnosis (13 and 15 respectively), so it is very unlikely that the use of these drugs at reevaluation accounted for the low rate of C-PA.…”

“…However, no studies have provided evidence for this theory nowadays. Moreover, patients with unilateral adenoma are usually the youngest among patients with PA (5,6), and cases of unilateral adenoma in newborns have also been described (7).…”