Prediction of successful outcome in patients with primary aldosteronism.
Sergical Service, Veterans Affairs Medical Center, 4150 Clement Street, San Francisco, CA 94121, USA.Current Treatment Options in Oncology (Impact Factor: 3.24). 08/2007; 8(4):314-21. DOI: 10.1007/s11864-007-0039-8
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.
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ABSTRACT: The objective of this study was to assess the long-term effects of adrenalectomy on the blood pressure and antihypertensive medication in patients with primary aldosteronism (PA). Twenty-four patients (15 female and 9 male) with a mean age of 48.3 +/- 10.8 years underwent surgery for PA in our institution between 1988 and 2001. All subjects were re-examined with a complete clinical work-up after a mean follow-up period of 86 +/- 48 months, including blood pressure readings (<140/90 mmHg defined as normal), endocrine adrenal function, and specific medication. All patients suffered from hypertension (onset 8.5 +/- 5.5 years prior to surgery). In 92% of the patients, hypokalemia was present (onset 2.0 +/- 2.6 years prior to surgery). The histopathologic examinations revealed unilateral adenomas in 23 patients and a bilateral hyperplasia in one patient. At follow-up, 33% (8) of the patients were completely cured (normal blood pressure and no antihypertensive treatment), with seven of these eight patients being under 50 years of age at the time of surgery. One patient revealed a contralateral aldosterone-secreting adrenal adenoma during the subsequent endocrine and imaging examination 44 months after the first operation. Despite normalized plasma-aldosterone concentration (PAC), plasma-renin-activity (PRA) and serum potassium levels, a long-lasting insufficiently treated hypertension due to the delayed diagnosis in patients with PA may explain the persistent blood pressure elevation, indicating the necessity of a life-long, regular control of the blood pressure and antihypertensive medication.World Journal of Surgery 02/2005; 29(2):155-9. DOI:10.1007/s00268-004-7496-z · 2.64 Impact Factor
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ABSTRACT: The aim of this report was to show that the rate of cardiovascular events is increased in patients with either subtype of primary aldosteronism (PA). Primary aldosteronism involves hypertension (HTN), hypokalemia, and low plasma renin. The two major PA subtypes are unilateral aldosterone-producing adenoma (APA) and bilateral adrenal hyperplasia. During a three-year period, the diagnosis of PA was made in 124 of 5,500 patients referred for comprehensive evaluation and management. Adenomas were diagnosed in 65 patients and idiopathic hyperaldosteronism in 59 patients. During the same period, clinical characteristics and cardiovascular events of this group were compared with those of 465 patients with essential hypertension (EHT) randomly matched for age, gender, and systolic and diastolic blood pressure. A history of stroke was found in 12.9% of patients with PA and 3.4% of patients with EHT (odds ratio [OR] = 4.2; 95% confidence interval [CI] 2.0 to 8.6]). Non-fatal myocardial infarction was diagnosed in 4.0% of patients with PA and in 0.6% of patients with EHT (OR = 6.5; 95% CI 1.5 to 27.4). A history of atrial fibrillation was diagnosed in 7.3% of patients with PA and 0.6% of patients with EHT (OR = 12.1; 95% CI 3.2 to 45.2). The occurrence of cardiovascular complications was comparable in both subtypes of PA. Patients presenting with PA experienced more cardiovascular events than did EHT patients independent of blood pressure. The presence of PA should be detected, not only to determine the cause of HTN, but also to prevent such complications.Journal of the American College of Cardiology 05/2005; 45(8):1243-8. DOI:10.1016/j.jacc.2005.01.015 · 16.50 Impact Factor
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