Treatment of Primary Aldosteronism and Reversal of Renin Suppression Improves Left Ventricular Systolic Function

Abstract

IntroductionPrimary aldosteronism (PA) is associated with increased risk of cardiovascular events. However, treatment of PA has not been shown to improve left ventricular (LV) systolic function using the conventional assessment with LV ejection fraction (LVEF). We aim to use speckle-tracking echocardiography to assess for improvement in subclinical systolic function after treatment of PA.MethodsWe prospectively recruited 57 patients with PA, who underwent 24-h ambulatory blood pressure (BP) measurements and echocardiography, including global longitudinal strain (GLS) assessment of left ventricle, at baseline and 12 months post-treatment.ResultsAt baseline, GLS was low in 14 of 50 (28.0%) patients. On multivariable analysis, GLS was associated with diastolic BP (P = 0.038) and glomerular filtration rate (P = 0.026). GLS improved post-surgery by −2.3, 95% CI: −3.9 to −0.6, P = 0.010, and post-medications by −1.3, 95% CI: −2.6 to 0.03, P = 0.089, whereas there were no changes in LVEF in either group. Improvement in GLS was independently correlated with baseline GLS (P < 0.001) and increase in plasma renin activity (P = 0.007). Patients with post-treatment plasma renin activity ≥1 ng/ml/h had improvements in GLS (P = 0.0019), whereas patients with persistently suppressed renin had no improvement. Post-adrenalectomy, there were also improvements in LV mass index (P = 0.012), left atrial volume index (P = 0.002), and mitral E/e’ (P = 0.006), whereas it was not statistically significant in patients treated with medications.ConclusionTreatment of hyperaldosteronism is effective in improving subclinical LV systolic dysfunction. Elevation of renin levels after treatment, which reflects adequate reversal of sodium overload state, is associated with better systolic function after treatment.Clinical Trial Registrationwww.ClinicalTrials.gov, identifier: NCT03174847.

Mortality in Patients With Primary Aldosteronism: A Swedish Nationwide Study

“…14 The importance of unsuppressed renin during treatment with MRA has also been shown to improve left ventricular systolic dysfunction, 28 as well as blood pressure and urinary albumin excretion. 29 Unfortunately, undertreatment of patients with PA seems to be common, 14,28,29 where inadequate follow-up, polypharmacy, and side-effects are important contributors. 30 The major strengths of our study are the large and unselected nationwide cohort of both medically and surgically treated patients with PA, and the long followup time.…”

“…By contrast, patients receiving higher MRA doses, and with unsuppressed renin, had comparable mortality to patients with essential hypertension. 14 The importance of unsuppressed renin during treatment with MRA has also been shown to improve left ventricular systolic dysfunction, 28 as well as blood pressure and urinary albumin excretion. 29 Unfortunately, undertreatment of patients with PA seems to be common, 14,28,29 where inadequate follow-up, polypharmacy, and side-effects are important contributors.…”

Unique characteristics of Asians with hypertension: what is known and what can be done?

“…However, there are differences in etiology of surgically remediable endocrine causes of secondary hypertension between Asian and Caucasians, with surgery for Conn's adenoma (67% of all cases) more common in Singapore, whereas pheochromocytoma (67% of all cases) more frequent in British patients [ 45 ]. Due to the direct deleterious effects of aldosterone, these patients are at greater risk of cardiac hypertrophy and dysfunction, which can potentially be reversed after adrenalectomy or mineralocorticoid-receptor antagonists (MRA) [ 46 , 47 ]. Further screening for secondary causes of hypertension is, therefore, recommended, especially in younger patients or those with drug-resistant hypertension.…”

Comparison of different medical treatments for primary hyperaldosteronism: a systematic review and network meta-analysis

“… 10 Accurate diagnosis and timely treatment of primary hyperaldosteronism not only cure this form of secondary hypertension but also reduce associated end-organ damage. 8 , 11 , 12 However, the real-world screening rate for primary hyperaldosteronism is low 13 and forms a major limitation to effective treatments of the disease. Surgical adrenalectomy is the recommended treatment for lateralized primary hyperaldosteronism.…”