Primary Aldosteronism

JACC State-of-the-Art Review

Highlights

• • PA is a common curable cause of hypertension and implies cardiovascular damage and events in excess of what is expected on the basis of the blood pressure elevation.

• • A wide range of hypertensive patients, particularly those with drug-resistant hypertension and lone atrial fibrillation, should be tested for PA.

• • Simplified strategies can identify those patients who can be cured long term with surgery.

• • Case detection testing for PA should be performed by measuring the aldosterone-renin ratio

• • Follow-up is recommended in both the surgically and the medically treated PA patients.

Abstract

Primary aldosteronism (PA) is a common, but frequently overlooked, cause of arterial hypertension and excess cardiovascular events, particularly atrial fibrillation. As timely diagnosis and treatment can provide a cure of hyperaldosteronism and hypertension, even when the latter is resistant to drug treatment, strategies to screen patients for PA early with a simplified diagnostic algorithm are justified. They can be particularly beneficial in some subgroups of hypertensive patients, as those who are at highest cardiovascular risk. However, identification of the surgically curable cases of PA and achievement of optimal results require subtyping with adrenal vein sampling, which, as it is technically challenging and currently performed only in tertiary referral centers, represents the bottleneck in the work-up of PA. Measures aimed at improving the clinical use of adrenal vein sampling and at developing alternative techniques for subtyping, alongside recommendations for drug treatment, including new development in the field, and for follow-up are discussed.