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A comprehensive review of the clinical aspects of primary aldosteronism

Nature Reviews Endocrinology volume 7, pages 485–495 (2011)Cite this article

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Abstract

Primary aldosteronism is much more common than previously thought. The high prevalence of primary aldosteronism, the damage this condition does to the heart, blood vessels and kidneys (which causes a high rate of cardiovascular events), along with the notion that a timely diagnosis followed by an appropriate therapy can correct the arterial hypertension and hypokalemia, justify efforts to search for primary aldosteronism in many patients with hypertension. Most centers can use a cost-effective strategy to screen for patients with primary aldosteronism. By contrast, the identification of primary aldosteronism subtypes, which involves adrenal-vein sampling, should only be undertaken at tertiary referral centers that have experience in performing and interpreting this test. The identification of a curable form of primary aldosteronism can be beneficial for the patient. In some subgroups of patients with hypertension who are at high risk of primary aldosteronism or can benefit most from an accurate diagnosis, an aggressive diagnostic approach is necessary.

Key Points

  • Primary aldosteronism is the most common endocrine cause of hypertension and is associated with damage to target organs (such as the heart and kidneys) and causes cardiovascular events

  • Primary aldosteronism is generally seen in patients with resistant hypertension, grade 2 or 3 hypertension, hypokalemia or incidentaloma, but can also occur in patients with mild hypertension

  • Screening for primary aldosteronism requires a careful pharmacological preparation of the patient and should be done by all physicians who deal with patients who have hypertension

  • The differentiation of subtypes of primary aldosteronism involves adrenal-vein sampling and should be undertaken at tertiary referral centers

  • Hyperaldosteronism and hypertension can be cured in the vast majority of patients with primary aldosteronism if the condition is diagnosed early

  • If adrenalectomy is performed upon demonstration of a lateralized aldosterone excess, primary aldosteronism is invariably cured and hypertension improves in >80% of patients

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Figure 1: The plots show the positive (circles and squares) and negative (diamonds and triangles) predictive value of PAC after the saline infusion test (blue) and after captopril challenge (red) as a function of the prevalence (pretest or prior probability) of APA in the patients of the PAPY study.
Figure 2: Diagnostic work-up of primary aldosteronism.

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Acknowledgements

The studies from G. P. Rossi's institution reported in this Review were mostly supported by research grants from FORICA (The Foundation for Advanced Research In Hypertension and Cardiovascular Diseases) and the Società Italiana dell'Ipertensione Arteriosa. This work was also supported by grants from the Ministry of University and Scientific Research (MIUR), The University of Padova and FORICA. C. P. Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape, LLC-accredited continuing medical education activity associated with this article.

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  1. Department of Clinical and Experimental Medicine (DMCS) 'Gino Patrassi', Internal Medicine 4, Policlinico Universitario, Via Giustiniani 2, Padova, 35126, Italy

    Gian Paolo Rossi

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Rossi, G. A comprehensive review of the clinical aspects of primary aldosteronism. Nat Rev Endocrinol 7, 485–495 (2011). https://doi.org/10.1038/nrendo.2011.76

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