Medical Versus Surgical Treatment of Primary Aldosteronism

See related article, pp 585–591 A growing body of literature associates primary aldosteronism (PA) with increased risk of cardiovascular complications, including cardiovascular attributable death, left ventricular hypertrophy, stroke, proteinuria, and atrial fibrillation. This increased cardiovascular risk is in no doubt related in large part to aldosterone-induced increases in blood pressure (BP), which are often resistant and severe. Additional mechanisms that are seemingly independent of increases in BP that likely contribute to the development and progression of cardiovascular disease in PA patients include aldosterone-induced inflammation, fibrosis, cellular hypertrophy, and oxidative stress.1 Further, in line with classical physiological effects, aldosterone and high dietary sodium exposure promotes intravascular fluid retention with associated increases in intracardiac heart volumes, including the left atrium, which would be anticipated to contribute to increased risk of incident atrial fibrillation.2 Demonstration of the increased risk of PA in relation to cardiovascular outcomes, including atrial fibrillation, has been largely based on retrospective or cross-sectional analyses. For example, in one of the earliest reports, Milliez et al3 retrospectively compared the history of specific cardiovascular events in 124 patients with confirmed PA and 465 control patients with primary hypertension. In spite of seemingly similar levels of BP control, the PA patients were significantly more likely to have had a history of stroke and myocardial infarction and were >12 times as likely to have been previously diagnosed with an episode of atrial fibrillation. Reincke et al4 conducted a longitudinal assessment of patients included in a German registry of PA who had been treated with adrenalectomy and a mineralocorticoid receptor antagonist (MRA). Although the 10-year all-cause mortality was similar to PA patients to that of matched hypertensive controls, the PA patients were significantly more likely to have died from cardiovascular complications than the control patients without PA. Combined, these 2 …