Primary aldosteronism: are we missing the wood for the trees?

Area of Science:

• Endocrinology
• Cardiovascular Medicine
• Pharmacology

Background:

• Primary aldosteronism (PA) affects 10% of hypertensive patients, posing a higher cardiovascular risk than essential hypertension (EH).
• Despite hypertension affecting 20% of the population, PA is significantly underdiagnosed and undertreated, with 99% of PA patients receiving suboptimal care.
• Mineralocorticoid receptor (MR) antagonists demonstrate efficacy, vasoprotective properties, and safety in managing hypertension.

Purpose of the Study:

• To evaluate the potential of low-dose MR antagonists as a first-line therapy for new-onset hypertension.
• To highlight the benefits of MR antagonists in both essential and resistant hypertension, and for undiagnosed PA.
• To advocate for the inclusion of MR antagonists in initial hypertension treatment strategies.

Main Methods:

• Review of existing literature on MR antagonist efficacy and safety in essential hypertension (EH) and resistant hypertension.
• Analysis of the prevalence and cardiovascular risks associated with primary aldosteronism (PA).
• Comparison of treatment outcomes for PA, including surgery versus MR antagonist therapy.

Main Results:

• MR antagonists effectively lower blood pressure and offer unique vasoprotective benefits in EH.
• In resistant hypertension, low-dose MR antagonists achieve significant blood pressure reduction (20-30 mm Hg).
• MR antagonist therapy is a viable, potentially non-inferior long-term option for unilateral PA compared to surgery.

Conclusions:

• A strong case exists for incorporating low-dose MR antagonists into first-line hypertension therapy due to their broad utility and safety.
• MR antagonists are particularly effective in resistant hypertension and beneficial for the large population with undiagnosed PA.
• Effective treatment for PA is feasible even without widespread diagnostic capabilities.