The forgotten cause of hypertension: A case report and literature review of the prevalence, diagnosis and management of primary aldosteronism

Abstract

In recent years, primary aldosteronism (PA) has been found to have a much higher prevalence than previously thought, especially among those with resistant hypertension. As hypertension has become a prominent public health issue affecting billions of people, the number of patients potentially affected by PA is a significant. Current medical and surgical therapies for PA are highly effective, and as untreated PA can lead to significant cardiovascular morbidity and mortality this stresses the importance of astute diagnosis and management on part of physicians. We present a case of a patient presenting with cardiovascular complications of untreated primary aldosteronism and review recent guidelines regarding screening, diagnosis, and management.Key Words: Conn's Syndrome, Adrenal hyperplasia, Primary aldosteronism, Hyperaldosteronism, Resistant hypertension BACKGROUNDPrimary aldosteronism (PA), or more commonly known as primary hyperaldosteronism, is the leading cause of secondary hypertension. [1,2] Once thought to be an uncommon disease, recent studies have shown that PA is increasingly common and present in anywhere from 5% to 10% of all those with hypertension. As hypertension is one of the most common chronic medical conditions, it is imperative that physicians involved in long-term management of these patients are familiar with recent guidelines surrounding PA diagnosis and management. When left undiagnosed, patients with primary aldosteronism have increased risk of cerebrovascular and cardiovascular events, which stresses the importance of proper screening, especially as current medical and surgical therapies are highly successful. We report a case of primary aldosteronism in a patient presenting with a cardiovascular event. Our case highlights the adverse complications of long standing primary aldosteronism and reviews the current literature regarding the prevalence of PA as well as its diagnosis and long-term management. CASE HISTORYA 65-year-old male with past medical history of poorly controlled hypertension presented to emergency department with acute onset substernal chest pain. His only known medical history was that of long-standing poorly controlled hypertension, that was self reported by the patient and confirmed by review of his previous blood pressure recordings and outpatient provider notes over the past several years in the hospital's electronic medical record. He was a lifelong non- Following the procedure, he remained hypertensive, despite up-titration to maximal doses of nifedipine, lisinopril and hydrochlorothiazide. He was also persistently hypokalemic with potassium levels ranging from 2.5 to 3.4 mmol/L, necessitating aggressive oral potassium supplementation. Given concern for secondary hypertension, plasma aldosterone and renin levels were drawn and were 17.5 ng/dl and 0.466 ng/ml/hr respectively, giving an elevated aldosterone renin ratio (ARR) of 37.5. A non-enhanced CT of the abdomen was performed and demonstrated slight enlargement and irregular thickening of the left adrenal...