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Lenzini L, Pintus G, Rossitto G, Seccia TM, Rossi GP. Primary Aldosteronism and Drug Resistant Hypertension: A "Chicken-Egg" Story. Exp Clin Endocrinol Diabetes 2023; 131:409-417. [PMID: 37054985 DOI: 10.1055/a-2073-3202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Drug-resistant arterial hypertension (RH) is a major risk factor for cardiovascular disease, often due to overlooked underlying causes. Identification of such causes poses significant clinical challenges. In this setting, primary aldosteronism (PA) is a frequent cause of RH and its prevalence in RH patients is likely higher than 20%.The pathophysiological link between PA and the development and maintenance of RH involves target organ damage and the cellular and extracellular effects of aldosterone excess that promote pro-inflammatory and pro-fibrotic changes in the kidney and vasculature.The feasibility of adrenal vein sampling in PA patients with RH, and the clinical benefit achieved by adrenalectomy, further emphasize the need to implement systematic screening for this common form of secondary hypertension in the management of a high-risk population as RH patients.: We herein review the current knowledge of the factors that contribute to the RH phenotype with a focus on PA and discuss the issues regarding the screening for PA in this setting and the therapeutic approaches (surgical and medical) aimed at resolving RH caused by PA.
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Affiliation(s)
- L Lenzini
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - G Pintus
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - G Rossitto
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - T M Seccia
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy
| | - G P Rossi
- Internal & Emergency Medicine Unit, Department of Medicine - DIMED, University of Padua, Padua, Italy
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10 good reasons why adrenal vein sampling is the preferred method for referring primary aldosteronism patients for adrenalectomy. J Hypertens 2020; 37:603-611. [PMID: 30431526 DOI: 10.1097/hjh.0000000000001939] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
: Nowadays most patients diagnosed with surgically curable primary aldosteronism have small or micro aldosterone-producing adenoma or unilateral micronodular hyperplasia, which are undetectable with available imaging technologies. Therefore, a negative imaging test by no means excludes unilateral primary aldosteronism. Moreover, about 10% of the subjects above the age of 35 years have nonfunctioning adrenal tumors, regardless of being hypertensive or not, with a prevalence that raises with aging. Hence, the finding of an adrenal mass at imaging does not reliably detect the culprit of primary aldosteronism. On the other hand, when primary aldosteronism patients are selected for adrenalectomy on the basis of demonstration of lateralized aldosterone excess at adrenal vein sampling (AVS), close to 100% are biochemically cured from the hyperaldosteronism, about 45% are cured of arterial hypertension and an additional 52% are markedly improved in terms of blood pressure control. By contrast, patients referred for surgery based on imaging alone often fail to reach these successful outcomes, indicating that surgery was unnecessary or, even worse, performed on the wrong side. For these reasons, and because of the lack of accurate and widely available alternative methods, all current guidelines recommend that AVS be offered to all primary aldosteronism patients with only few exceptions, mainly in patients unable or unwilling to undergo surgery and those with germ-line mutations causing familial primary aldosteronism. The main argument against systematic use of AVS entails its suboptimal performance, partly justified by its intrinsic technical difficulty, and its limited availability. This led to propose skipping AVS strategies for predicting surgically curable primary aldosteronism, but success has been inconsistent. The most urgent standing issue is, therefore, not to find loopholes to avoid AVS, but rather to improve its use, which means improving the rate of AVS success, through formal training of interventionists, selection of appropriate cutoffs and exploitation of a standardized procedure.
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Abstract
Primary aldosteronism (PA) is a highly prevalent cause of arterial hypertension featuring excess cardiovascular events. A timely diagnosis and treatment of PA cures hyperaldosteronism and can provide resolution or improvement of arterial hypertension, even when the latter is resistant to drug treatment. Accordingly, strategies to screen early and widely the hypertensive patients for PA by means of simplified diagnostic algorithms are justified. Such strategies are particularly beneficial in subgroups of hypertensive patients, who are at the highest cardiovascular risk. Broadening of screening strategies means facing with an increased number of patients where monitoring the disease becomes necessary. Hence, after identification of the surgically and non surgically curable cases of PA and implementation of targeted treatment physicians are faced with the challenges of follow-up, which are scantly discussed in the literature. Hence, the purpose of this paper is to provide some recommendations on how to optimize the monitoring of patients in whom the PA subtype has been diagnosed and treatment, either with unilateral laparoscopic adrenalectomy or medically, has been instituted.
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Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Livia Lenzini
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
| | - Teresa M Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy.
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O'Shea PM, O'Donoghue D, Bashari W, Senanayake R, Joyce MB, Powlson AS, Browne D, O'Sullivan GJ, Cheow H, Mendichovszky I, Quill D, Lowery A, Lappin D, Gurnell M, Dennedy MC. 11 C-Metomidate PET/CT is a useful adjunct for lateralization of primary aldosteronism in routine clinical practice. Clin Endocrinol (Oxf) 2019; 90:670-679. [PMID: 30721535 DOI: 10.1111/cen.13942] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Revised: 01/08/2019] [Accepted: 01/30/2019] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To describe clinical practice experience of 11 C-Metomidate PET/CT as an adjunct to adrenal vein sampling (AVS) in the lateralization of aldosterone-producing adenomas (APA) in primary aldosteronism (PA). CONTEXT Accurate lateralization of APA in the setting of PA offers the potential for surgical cure and improved long-term cardiovascular outcomes. Challenges associated with AVS, the current gold standard lateralization modality, mean that only a small proportion of potentially eligible patients currently make it through to surgery. This has prompted consideration of alternative strategies for lateralization, including the application of novel molecular PET tracers such as 11 C-Metomidate. DESIGN Clinical Service Evaluation/Retrospective audit. PATIENTS Fifteen individuals with a confirmed diagnosis of PA, undergoing lateralization with 11 C-Metomidate PET/CT prior to final clinical decision on surgical vs medical management. MEASUREMENTS All patients underwent screening aldosterone renin ratio (ARR), followed by confirmatory testing with the seated saline infusion test, according to Endocrine Society Clinical Practice Guidelines. Adrenal glands were imaged using dedicated adrenal CT. 11 C-Metomidate PET/CT was undertaken due to equivocal or failed AVS. Management outcomes were assessed by longitudinal measurement of blood pressure, ARR, number of hypertensive medications following adrenalectomy or institution of medical therapy. RESULTS We describe the individual lateralization and clinical outcomes for 15 patients with PA. CONCLUSION 11 C-Metomidate PET/CT in conjunction with adrenal CT and AVS provided useful information which aided clinical decision-making for PA within a multidisciplinary hypertension clinic.
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Affiliation(s)
- Paula M O'Shea
- Department of Clinical Biochemistry, Galway University Hospital, Galway, Ireland
| | - Darragh O'Donoghue
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
| | - Waiel Bashari
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Russell Senanayake
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Mary B Joyce
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
| | - Andrew S Powlson
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Darragh Browne
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
| | | | - Heok Cheow
- Department of Nuclear Medicine, Addenbrooke's Hospital, Cambridge, UK
| | | | - Denis Quill
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - Aoife Lowery
- Department of Surgery, Galway University Hospital, Galway, Ireland
| | - David Lappin
- Department of Nephrology, Galway University Hospital, Galway, Ireland
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, UK
| | - Michael C Dennedy
- Discipline of Pharmacology and Therapeutics, School of Medicine, National University of Ireland, Galway, Ireland
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Cesari M, Ceolotto G, Rossitto G, Maiolino G, Seccia TM, Rossi GP. The Intra-Procedural Cortisol Assay During Adrenal Vein Sampling: Rationale and Design of a Randomized Study (I-Padua). High Blood Press Cardiovasc Prev 2017; 24:167-170. [DOI: 10.1007/s40292-017-0192-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 03/09/2017] [Indexed: 11/29/2022] Open
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