Prediction of successful outcome in patients with primary aldosteronism

Primary aldosteronism is one of the most common causes of secondary hypertension. In recent years the prevalence has risen dramatically, from 1% to 14% of all hypertensive patients. This has been largely attributed to an increase in diagnosis. Primary aldosteronism is characterized by hypertension with or without hypokalemia and a high plasma aldosterone concentration (PAC) with a concurrent low plasma renin activity (PRA). The most common subtypes of primary aldosteronism are aldosterone-producing adenoma (42%) and bilateral idiopathic hyperaldosteronism (58%). Other less common subtypes (<1%) are glucocorticoid-remediable aldosteronism, and unilateral primary hyperplasia. Current treatment for primary aldosteronism relies on accurate subtype distinction and assessment of unilateral versus bilateral disease. Bilateral idiopathic hyperaldosteronism is best managed pharmacologically and improves with the use of aldosterone receptor antagonists. Combined treatment with sodium-channel blockers and calcium-channel blockers has also shown satisfactory results. Glucocorticoid-remediable aldosteronism responds well to treatment with low-dose glucocorticoids. Aldosterone producing adenoma and unilateral adrenal hyperplasia are appropriately treated with laparoscopic adrenalectomy. Following adrenalectomy blood pressure improves in 98% of these patients, but only about 33% require no further antihypertensive medication. Identifying the subgroups that will most benefit from adrenalectomy is paramount to formulating individual treatment strategies. In the past, treatment focused mainly on the correction of hypertension and electrolyte disturbances. Now, with accumulating evidence of the detrimental effects of aldosterone to the myocardium, vascular endothelium and kidneys, treatment also focuses on normalizing aldosterone levels or blocking aldosterone action at the receptor level. Therefore, it is essential to accurately identify the specific subtype of primary aldosteronism in order to select optimal treatment and to achieve successful patient outcomes.