Aldosterone and Impaired Nocturnal Blood Pressure Decline in Primary Aldosteronism

The loss of physiological nocturnal blood pressure (BP) decline is a major contributor to cardiovascular risk, yet its endocrine underpinnings in primary aldosteronism (PA) remain underexplored. This study aimed to elucidate the dose-dependent relationship between aldosterone excess and circadian BP rhythm disruption and assess whether targeted aldosterone suppression could ameliorate nocturnal dipping.

We prospectively analyzed 24-hour ambulatory BP data from 681 patients with confirmed PA, stratified by plasma aldosterone concentration. A subset of 99 patients with adrenal vein sampling-confirmed unilateral PA received targeted, minimally invasive vascular intervention for aldosterone suppression and were evaluated for changes in BP rhythm on the basis of treatment response.

In multivariable-adjusted models, both log-transformed plasma aldosterone concentration and aldosterone-to-renin ratio were inversely associated with the proportion of nocturnal systolic BP decline (log plasma aldosterone concentration: β=-0.054 [95% CI, -0.087 to -0.020]; P=0.002; log aldosterone-to-renin ratio: β=-0.016 [95% CI, -0.025 to -0.006]; P=0.001). In patients achieving biochemical remission after selective suppression, nighttime systolic BP decreased significantly (mean reduction=-33 mm Hg; Cohen's d_z=2.113). The prevalence of the dipper pattern increased from 14.5% to 39.1% (P<0.001), while no rhythm improvement was observed in nonresponders. Multivariable regression confirmed biochemical success as an independent predictor of nocturnal dip amelioration (P=0.045), irrespective of adrenal imaging phenotype.

Aldosterone excess contributes directly to circadian BP rhythm disruption in PA. Selective hormonal suppression can ameliorate physiological BP dipping in responsive patients. These findings highlight the value of rhythm-based end points and support aldosterone-targeted modulation as a strategic goal in PA management. Registration: URL: https://www.chictr.org.cn/; Unique Identifier: ChiCTR2200057297.