Composite Cardiovascular Outcomes in Patients With Primary Aldosteronism Undergoing Medical versus Surgical Treatment: A Meta-Analysis

Background Superior performance of surgical treatment over medical treatment for primary aldosteronism (PA) has been reported in small-scale clinical studies with diverse clinical outcomes, but no solid conclusion has been drawn as results of large randomized trials are lacking. Methods: We performed a search of PubMed, MEDLINE, Embase and Cochrane Library for randomized or observational studies that investigated cardiovascular outcomes in patients with primary aldosteronism undergoing medical versus surgical treatment. - Composite outcomes including persistence of hypertension (HT) and incidence of significant clinical events (e.g. major adverse cardiovascular events [MACE] and all-cause mortality) after treatment was considered. Meta-analyses of both composite and individual outcomes were conducted. Risks of bias of the included studies were assessed with Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) checklist. Findings: A total of 368 related citations were reviewed and 11 studies that fulfilled the inclusion criteria, with altogether 5,994 PA patients, were included in the meta-analysis. Evaluation showed that there were low-moderate risks of bias in (63.64%) 7 of the included studies. The results of meta-analyses demonstrated lower incidence of composite outcomes among PA patients who underwent surgical treatment over medical treatment (Odds Ratio (OR): 0.49, 95% CI: 0.29-0.83 in random effects model). Surgical treatment also led to less incidence of persistence of HT (OR of non-cure of HT: 0.31, 95% CI: 0.11-0.85 in random effects model). Fewer major cardiovascular events and mortality events after surgical treatment were observed in the fixed effect model (OR: 0.47, 95% CI: 0.39-0.56), but failed to reach significant statistical levels in random effects model (OR: 0.71, 95% CI: 0.33-1.52) when compared to medical treatment. Interpretation: Superior performance of surgical treatment over medical treatment for PA patients is confirmed with meta-analyses in terms of lower incidences of composite outcomes and non-cure of HT. Hence, adrenalectomy could now be concluded as the treatment of choice for lateralized PA. Funding Statement: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Declaration of Interests: All authors declare no competing interests Ethics Approval Statement: The pre-defined review protocol was registered at the PROSPERO international prospective register of systematic reviews (PROSPERO registration number CRD42019119175). The protocol for this trial and supporting CONSORT checklist are available as supporting information.