Comparison of left ventricular structure and function in primary aldosteronism and essential hypertension by echocardiography

Comparison of saline infusion test and captopril challenge test in the diagnosis of Chinese with primary aldosteronism in different age groups

Background

To explore the diagnostic accuracy and the optimal cutoff value between the saline infusion test (SIT) and captopril challenge test (CCT) [including the value and suppression of plasma aldosterone concentration (PAC)] for primary aldosteronism (PA) diagnosing.

Methods

A total of 318 patients with hypertension were consecutively enrolled, including 126 patients with PA and 192 patients with essential hypertension (EH), in this observational study. The characteristics of patients and laboratory examinations were collected and compared. The comparison between SIT and CCT was carried by drawing the receiver operator characteristic curve (ROC) and calculating the area under the curve (AUC) to explore the diagnostic accuracy and the optimal cutoff value.

Results

The average age was 51.59 ± 10.43 in the PA group and 45.72 ± 12.44 in the EH group (p<0.05). The optimal cutoff value was 10.7 ng/dL for post-CCT PAC, 6.8 ng/dL for post-SIT PAC, and 26.9% for suppression of post-CCT PAC. The diagnostic value of post-CCT PAC was the highest with 0.831 for the AUC and 0.552 for the Youden index. The optimal cutoff value for patients who were <50 years old was 11.5 ng/dL for post-CCT PAC and 8.4 ng/dL for post-SIT PAC. The suppression of post-CCT PAC turned to 18.2% for those of age 50 or older.

Conclusion

Compared with SIT, CCT had a higher diagnostic value when post-CCT PAC was used as the diagnostic criterion in Chinese people, while the selection of diagnostic thresholds depended on patient age.

Aldosterone Effect on Cardiac Structure and Function

BACKGROUND

Cardiac remodelling could be a key mechanism in aldosteronemediated cardiovascular morbidity and mortality. Experimental and clinical evidence has demonstrated that aldosterone causes cardiac structural remodelling and dysfunction by its profibrotic and pro-hypertrophic effects, which result mainly from the direct effects on myocardial collagen deposition, inflammation, and oxidative stress. Clinical studies have investigated the aldosterone effects on the heart in different clinical conditions, including general population, essential hypertension, primary aldosteronism, heart failure, and atrial fibrillation. Robust findings indicate that aldosterone or the activation of the cardiac mineralocorticoid receptor can cause damage to myocardial tissue by mechanisms independent of the blood pressure, leading to tissue hypertrophy, fibrosis, and dysfunction.

CONCLUSION

Aldosterone-mediated cardiovascular morbidity and mortality mainly result from cardiac structural and functional alterations. In different clinical settings, aldosterone can induce cardiac structural remodelling and dysfunction via several pathological mechanisms, including cardiac fibrosis, inflammation, and oxidative stress. Aldosterone antagonists could effectively decrease or reverse the detrimental aldosterone-mediated changes in the heart.

Subclinical HMOD in Hypertension: Left Ventricular Diastolic Dysfunction

Arterial hypertension represents an important risk factor for the development of cardiac, vascular and renal events, predisposing to heart failure, acute coronary syndromes, peripheral artery disease, stroke, and chronic renal disease. Arterial hypertension leads to the development of subclinical hypertension mediated organ damage (HMOD) which has prognostic relevance and may influence the choice of treatment options. Alterations of cardiac structure and function represent the more widely assessed form of HMOD. This manuscript will focus on the diagnostic opportunities, prognostic significance and treatment of diastolic dysfunction alterations.

The differences of serum lipid profiles between primary aldosteronism and essential hypertension: a meta-analysis and systematic review

BACKGROUND

The data on lipid profile differences between primary aldosteronism (PA) and essential hypertension (EH) patients are inconsistent and inconclusive. Most studies reported lower levels of lipid profiles in PA than in EH. This meta-analysis aimed to explore differences in serum lipid profiles including triglyceride (TG), total cholesterol (TC), LDL and HDL levels in PA patients and EH patients.

METHODS

A search of published studies was performed using PubMed, Embase and Scopus databases from their inception through August 2022. Thirty studies involving 11,175 patients were identified. Inclusion criteria included 1) observational studies which contained data on any of the lipid profiles of interest (TG, TC, LDL and HDL) which could be acquired from baseline data or the outcomes, 2) data which should be compared between adult PA and EH patients and 3) the use of appropriate methods to diagnose PA. Standardized mean difference (SMD) with a 95% confidence interval (95% CI) was calculated to assess effect size by using STATA program version 15.0. Risk of bias was assessed by Joanna Briggs Institute (JBI) Critical Appraisal Tools for cross-sectional, cohort and case-control studies.

RESULTS

Levels of the lipid parameters TG (SMD - 0.16 mmol/L; 95%CI (- 0.25, - 0.07)), TC (SMD - 0.30 mmol/L; 95%CI (- 0.41, - 0.19)) and LDL (SMD - 0.17 mmol/L; 95%CI (- 0.27, - 0.08)) were significantly lower in PA than in EH patients. There was no statistically significant difference in HDL between PA and EH patients (SMD - 0.08 mmol/L; 96%CI (- 0.23,0.07)). High levels of heterogeneity for TG, TC, HDL and LDL were observed in all studies. Risk of bias among the studies was low to moderate.

CONCLUSION

Lower levels of TG, TC and LDL were observed in PA than in EH patients. Further study should be conducted to address the underlying mechanisms of lipid alteration in PA.

Differences in Glycemic Abnormalities Between Primary Aldosteronism and Essential Hypertension: A Systematic Review and Meta-Analysis

Background

The relationship of glycemic abnormalities between primary aldosteronism (PA) patients and essential hypertension (EH) patients is still debatable. This meta-analysis aimed to explore differences in the prevalence of glycemic abnormalities and levels of abnormal glucose metabolism in PA and EH patients.

Methods

A search was performed using PubMed, Scopus, Cochrane and Web of Science databases from their inception through January 2022. Inclusion criteria for this study were 1) observational studies which contained specific data of interest, 2) studies including data which compared adult PA and EH patients and 3) studies which used appropriate methods to diagnose PA. Risk ratio (RR) or standardized mean difference (SMD) with a 95% confidence interval (95% CI) was calculated.

Results

Twenty-six studies involving 53,186 patients were included in the meta-analysis. Patients with PA demonstrated significantly higher overall incidence of glycemic abnormalities than patients with EH [RR 1.54; 95% CI (1.20,1.98)]. Risk of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in PA patients were higher than in EH patients [RR 1.27; 95%CI (1.08, 1.49) and RR 2.99; 95%CI (1.74, 5.16), respectively]. There was no statistically significant difference of risk between these groups for impaired fasting glucose (IFG) [RR 1.70; 95%CI (0.55, 5.26)]. Moderate heterogeneity was observed in overall glycemic abnormalities outcomes. A high level of heterogeneity was observed for IFG, while the level was low for DM and IGT.

Conclusions

PA patients have a higher risk of glycemic abnormalities than in EH patients. Further study should be conducted to investigate underlying mechanisms of glycemic abnormalities in PA.

Systematic Review Registration

www.inplasy.com, INPLASY, identifier 202220004.

Strain Imaging for the Early Detection of Cardiac Remodeling and Dysfunction in Primary Aldosteronism

Speckle tracking echocardiography is a novel technique to quantify cardiac function and deformation. It has been applied in a series of cardiovascular diseases for the evaluation of early cardiac impairment. We recently used this technique to investigate cardiac structure and function in patients with primary aldosteronism. Cardiac damage usually occurs earlier in patients with primary aldosteronism than those with primary hypertension, probably because aldosterone hypersecretion is more commonly observed in the former than the latter patients. In this article, we will review the imaging studies, especially with speckle tracking echocardiography, for the detection of early cardiac dysfunction in primary aldosteronism as a disease model.

Cerebro-Cardiovascular Risk, Target Organ Damage, and Treatment Outcomes in Primary Aldosteronism

Primary aldosteronism (PA) is the most common type of endocrine hypertension, and numerous experimental and clinical evidence have verified that prolonged exposure to excess aldosterone is responsible for an increased risk of cerebro-cardiovascular events and target organ damage (TOD) in patients with PA. Therefore, focusing on restoring the toxic effects of excess aldosterone on the target organs is very important to reduce cerebro-cardiovascular events. Current evidence convincingly demonstrates that both surgical and medical treatment strategies would benefit cerebro-cardiovascular outcomes and mortality in the long term. Understanding cerebro-cardiovascular risk in PA would help clinical doctors to achieve both early diagnosis and treatment. Therefore, in this review, we will summarize the cerebro-cardiovascular risk in PA, focusing on the TOD of aldosterone, including brain, heart, vascular system, renal, adipose tissues, diabetes, and obstructive sleep apnea (OSA). Furthermore, the various treatment outcomes of adrenalectomy and medical treatment for patients with PA will also be discussed. We hope this knowledge will help improve cerebro-cardiovascular prognosis and reduce the incidence and mortality of cerebro-cardiovascular events in patients with PA.

Left ventricular global longitudinal strain in secondary hypertension: A meta-analysis of echocardiographic studies

AIM

Information on systolic dysfunction, as assessed by left ventricular (LV) mechanics in secondary hypertension is still largely limited. We performed a systematic meta- analysis of 2D/3D speckle tracking studies in order to provide an updated comprehensive information on this topic.

METHODS

The PubMed, OVID-MEDLINE, and Cochrane library databases were analysed to search for articles published from the inception up to March 31st 2021. Studies were identified by using MeSH terms and crossing the following search items: "myocardial strain" "left ventricular mechanics", "speckle tracking echocardiography", "systolic dysfunction", "hypertensive heart disease", "left ventricular hypertrophy", "secondary hypertension", "primary aldosteronism", "pheochromocytoma", "Cushing disease", "renal artery stenosis".

RESULTS

On the whole, 515 patients with secondary hypertension (169 pheochromocytoma, 165 primary aldosteronism, 144 renal artery stenosis and 37 Cushing's syndrome) and 601 essential hypertensive patients from 11 studies were considered. Pooled ejection fraction (EF) was similar in essential hypertensive controls and in patients with secondary hypertension (SMD 0.12±0.06, CI: 0.001/0.25, p=0.05). Of note, EF was higher in patients with pheochromocytoma than in essential hypertensives (0.50±0.11, CI: 0.27/0.73, p<0.001). In contrast, pooled GLS was impaired in patients with secondary hypertension compared to their essential hypertensive counterparts (SMD 0.83±0.26, CI: 0.32/1.30, p< 0.001).

CONCLUSIONS

The present meta-analysis adds a new piece of evidence by showing that GLS performs better than EF in identifying systolic dysfunction in the setting of secondary hypertension. In particular, this is true in patients with pheochromocytoma in whom conventional EF suggests a normal or even super-normal systolic function.

Association between polymorphisms of genes involved in the Renin-Angiotensin-Aldosterone System and the adaptive morphological and functional responses to essential hypertension

Hypertensive cardiac remodeling is illustrated by increased left ventricular (LV) mass index values and/or relative wall thickness (RWT) values >0.42, and functionally by isolated alteration of LV diastole (abnormal relaxation). The aim of the present study was to establish differentiated models of anatomical and functional adaptation to essential hypertension (EHT), in relation to the genetic variants of genes involved in the Renin-Angiotensin-Aldosterone System (RAAS). The M235T-AGT, I/D-ACE, A1166C-R1AngII, A3123C-R2AngII and G83A-REN genotypes were determined using PCR-Restriction Fragment Length Polymorphism in 139 hypertensive subjects. The relationship between the studied RAAS gene polymorphisms with morphological and functional cardiac remodeling was assessed by multiple logistic regression analysis. Patients carrying the C/C, A/C genotypes (A3123C-R2AngII polymorphism) had a 2.72-fold (P=0.033) increased risk of exhibiting an RWT value <0.42; in the multivariate model the risk was 4.02-fold higher (P=0.008). Analysis of LV diastolic dysfunction (LVDD) revealed that hypertensive patients carrying the T/T, M/T genotypes (M235T-AGT polymorphism) had a 2.24-fold (P=0.037) increased risk of developing LVDD and a 2.42-fold increased risk (P=0.039) after adjustment for confounders. Similarly, carriers of the G/G, A/G genotypes (G83A-REN) had a 2.32-fold (P=0.021) increased risk of developing LVDD, and this remained an independent risk factor based on the multivariate model (P=0.033). The results of the present study showed that no particular gene was associated with increased LV mass, but the A3123C-R2AngII polymorphism was associated with a non-concentric type of cardiac response in hypertensive patients. Conversely, the M235T-AGT and G83A-REN polymorphisms were found to be statistically significantly associated with LVDD when assessing abnormal relaxation.

Correlation between serum miR-122 and myocardial damage and ventricular function in patients with essential hypertension

Background

Myocardial damage and decreased ventricular function are risk factors leading to a bad prognosis in patients with essential hypertension (EH). MicroRNAs play important roles in myocardial function impairment in patients with hypertension. The purpose of our research was to investigate the correlation between serum miR-122 and myocardial damage and ventricular functions in EH patients.

Methods

The clinic data of EH patients (group A, n=60) and healthy individuals (group B, n=60) from December 2016 to December 2019 in our hospital were collected and analyzed. Serum miR-122, myocardial damage markers [B-type brain natriuretic peptide (BNP), homocysteine (Hcy), cardiac troponin T (cTnT) and creatine kinase MB isoenzyme (CK-MB)] and cardiac function indicators [ejection fraction (EF), left ventricular septal thickness (IVST), left ventricular isovolumic relaxation time (IVRT), left ventricular end-diastolic diameter (LVEDD), left ventricular posterior wall thickness (LVPWT), and left ventricular end-systolic diameter (LVESD)] were assessed in both groups. The correlation between serum miR-122 and myocardial damage markers and ventricular function indicators was analyzed.

Results

(I) The mean serum miR-122 concentration in group A and group B was 6.86±1.23 and 3.36±1.87 µmol/L, respectively. The serum miR-122 concentration in group A was evidently increased compared with that in group B. (II) The levels of BNP, Hcy, cTnT, and CK-MB in the peripheral blood in group A were evidently increased compared with those in group B (P<0.05). (III) EF and IVRT were evidently decreased in group A compared with that in group B (P<0.05). (IV) Serum miR-122 concentration was positively correlated with the myocardial damage markers BNP, Hcy, cTnT and CK-MB, and serum miR-122 concentration was negatively correlated with the ventricular function indicators EF and IVRT but not significantly correlated with other ventricular function indicators (IVST, LVEDD, LVPWT and LVESD).

Conclusions

The serum miR-122 concentration in EH patients was higher than that in healthy individuals, and miR-122 concentration was positively correlated with myocardial damage markers. Serum miR-122 level was negatively correlated with the ventricular function indicators EF and IVRT but was not significantly correlated with other ventricular function indicators (IVST, LVEDD, LVPWT, and LVESD).

A non-invasive left ventricular pressure-strain loop study on myocardial work in primary aldosteronism

We investigated the myocardial work derived from left ventricular pressure-strain loop in patients with primary aldosteronism or primary hypertension. We enrolled 50 patients with primary aldosteronism, 50 age- and sex-matched patients with primary hypertension, and 25 normotensive control subjects. We performed transthoracic echocardiography and speckle-tracking echocardiography-based left ventricular pressure-strain loop analysis to evaluate cardiac structure and function. Patients with primary aldosteronism and those with primary hypertension had similar clinic and ambulatory blood pressures, except that the former had a significantly (P = 0.03) higher nighttime systolic blood pressure. All subjects had normal left ventricular ejection fraction (66.4 ± 4.7%). Patients with primary aldosteronism had a greater left ventricular mass index than those with primary hypertension and the normal controls (111.0 ± 21.6 g/m² versus 95.7 ± 17.7 and 77.9 ± 13.5 g/m², respectively, P < 0.001). The global myocardial work index (GWI, 2336 ± 333, 2366 ± 288, and 2292 ± 249 mmHg%, respectively), and global constructive work (GCW, 2494 ± 325, 2524 ± 301, and 2391 ± 193 mmHg%, respectively), were comparable in the three groups (P ≥ 0.18). However, the global work efficiency (GWE) differed significantly (P < 0.001), being lowest in primary aldosteronism (91.1 ± 2.7%), intermediate in primary hypertension (93.5 ± 2.5%) and highest in controls (95.3 ± 1.5%). The opposite was true for the global wasted work (GWW) (205.6 ± 74.6, 142.0 ± 56.4 and 99.4 ± 33.7 mmHg%, respectively, P < 0.001). GWE was significantly correlated with the logarithmically transformed plasma concentration and the urinary excretion of aldosterone in patients with primary aldosteronism or primary hypertension (r = -0.43 for both, P < 0.001). The associations remained statistically significant (P ≤ 0.04) after further adjustment for several factors, including left ventricular mass index and clinic or nighttime blood pressure. In conclusion, GWE decreased and GWW increased in primary hypertension and further in primary aldosteronism, probably because of the adrenal aldosterone hypersecretion and the left ventricular mass index increase, while GWI and GCW were similar, indicating that similar and normalized total myocardial work might be a compensation in hypertension at the expense of work efficiency.

Association of Systolic Blood Pressure Elevation With Disproportionate Left Ventricular Remodeling in Very Preterm-Born Young Adults: The Preterm Heart and Elevated Blood Pressure

Question

Are left ventricular structure and function in preterm-born adults more susceptible to remodeling in association with blood pressure elevation?

Findings

In this cross-sectional cohort study of 468 adults with cardiac magnetic resonance imaging, left ventricular mass index and mass to end-diastolic volume ratio were greater for each 1–mm Hg elevation in systolic blood pressure in preterm-born adults than in term-born adults, with the greatest rise in those born very and extremely preterm (<32 weeks’ gestation).

Meaning

The findings of this study show that adults born preterm demonstrate greater remodeling in response to systolic blood pressure elevation and may require earlier interventions to prevent cardiovascular disease progression.

Importance

Preterm-born individuals have higher blood pressure with an increased risk of hypertension by young adulthood, as well as potentially adverse cardiac remodeling even when normotensive. To what extent blood pressure elevation affects left ventricular (LV) structure and function in adults born preterm is currently unknown.

Objective

To investigate whether changes observed in LV structure and function in preterm-born adults make them more susceptible to cardiac remodeling in association with blood pressure elevation.

Design, Setting, and Participants

This cross-sectional cohort study, conducted at the Oxford Cardiovascular Clinical Research Facility and Oxford Centre for Clinical Magnetic Resonance Research, included 468 adults aged 18 to 40 years. Of these, 200 were born preterm (<37 weeks’ gestation) and 268 were born at term (≥37 weeks’ gestation). Cardiac magnetic resonance imaging was used to characterize LV structure and function, with clinical blood pressure readings measured to assess hypertension status. Demographic and anthropometric data, as well as birth history and family medical history information, were collected. Data were analyzed between January 2012 and February 2021.

Main Outcomes and Measures

Cardiac magnetic resonance measures of LV structure and function in response to systolic blood pressure elevation.

Results

The cohort was primarily White (>95%) with a balanced sex distribution (51.5% women and 48.5% men). Preterm-born adults with and without hypertension had higher LV mass index, reduced LV function, and smaller LV volumes compared with term-born individuals both with and without hypertension. In regression analyses of systolic blood pressure with LV mass index and LV mass to end-diastolic volume ratio, there was a leftward shift in the slopes in preterm-born compared with term-born adults. Compared with term-born adults, there was a 2.5-fold greater LV mass index per 1–mm Hg elevation in systolic blood pressure in very and extremely preterm-born adults (<32 weeks’ gestation) (0.394 g/m² vs 0.157 g/m² per 1 mm Hg; P < .001) and a 1.6-fold greater LV mass index per 1–mm Hg elevation in systolic blood pressure in moderately preterm-born adults (32 to 36 weeks’ gestation) (0.250 g/m² vs 0.157 g/m² per 1 mm Hg; P < .001). The LV mass to end-diastolic volume ratio per 1–mm Hg elevation in systolic blood pressure in the very and extremely preterm-born adults was 3.4-fold greater compared with those born moderately preterm (3.56 × 10⁻³ vs 1.04 × 10⁻³ g/mL per 1 mm Hg; P < .001) and 3.3-fold greater compared with those born at term (3.56 × 10⁻³ vs 1.08 × 10⁻³ g/mL per 1 mm Hg; P < .001).

Conclusions and Relevance

Preterm-born adults have a unique LV structure and function that worsens with systolic blood pressure elevation. Additional primary prevention strategies specifically targeting cardiovascular risk reduction in this population may be warranted.

Left Ventricular Remodeling in Patients with Primary Aldosteronism: A Prospective Cardiac Magnetic Resonance Imaging Study

Objective

This study used cardiac magnetic resonance imaging (MRI) to compare the characteristics of left ventricular remodeling in patients with primary aldosteronism (PA) with those of patients with essential hypertension (EH) and healthy controls (HCs).

Materials and Methods

This prospective study enrolled 35 patients with PA, in addition to 35 age- and sex-matched patients with EH, and 35 age- and sex-matched HCs, all of whom underwent comprehensive clinical and cardiac MRI examinations. The analysis of variance was used to detect the differences in the characteristics of left ventricular remodeling among the three groups. Univariable and multivariable linear regression analyses were used to determine the relationships between left ventricular remodeling and the physiological variables.

Results

The left ventricular end-diastolic volume index (EDVi) (mean ± standard deviation [SD]: 85.1 ± 13.0 mL/m² for PA, 75.9 ± 14.3 mL/m² for EH, and 77.3 ± 12.8 mL/m² for HC; p = 0.010), left ventricular end-systolic volume index (ESVi) (mean ± SD: 35.2 ± 9.8 mL/m² for PA, 30.7 ± 8.1 mL/m² for EH, and 29.5 ± 7.0 mL/m² for HC; p = 0.013), left ventricular mass index (mean ± SD: 65.8 ± 16.5 g/m² for PA, 56.9 ± 12.1 g/m² for EH, and 44.1 ± 8.9 g/m² for HC; p < 0.001), and native T1 (mean ± SD: 1224 ± 39 ms for PA, 1201 ± 47 ms for EH, and 1200 ± 44 ms for HC; p = 0.041) values were higher in the PA group compared to the EH and HC groups. Multivariable linear regression demonstrated that log (plasma aldosterone-to-renin ratio) was independently correlated with EDVi and ESVi. Plasma aldosterone was independently correlated with native T1.

Conclusion

Patients with PA showed a greater degree of ventricular hypertrophy and enlargement, as well as myocardial fibrosis, compared to those with EH. Cardiac MRI T1 mapping can detect left ventricular myocardial fibrosis in patients with PA.

Diurnal blood pressure pattern and cardiac damage in hypertensive patients with primary aldosteronism

PURPOSE

The aim of our study was to evaluate the relationship between the 24-h blood pressure (BP) profile, plasma NT-proBNP levels and left ventricular hypertrophy (LVH) in subjects with primary aldosteronism (PA) compared to patients with essential hypertension (EH).

METHODS

A total of 385 consecutive patients with PA [187 with aldosterone producing adenoma (APA) and 198 with idiopathic hyperaldosteronism (IHA)] and 385 patients with EH were matched based on age, sex, body mass index (BMI), BP values and duration of hypertension. Twenty-four-hour ambulatory BP monitoring (ABPM), plasma levels of NT-proBNP, left ventricular mass index (LVMI), and other clinical medical data were assessed in all patients.

RESULTS

No differences in age, sex, BMI, clinical BP, 24-h mean BP, daytime BP, or duration of hypertension were found between groups. Nighttime systolic BP (130 ± 16 vs. 127 ± 17 mmHg, p < 0.05) and diastolic BP (82 ± 10 vs. 79 ± 11 mmHg, p < 0.01) were higher in PA patients than in EH patients. In addition, nocturnal BP decline was reduced, while median NT-proBNP (53.7 vs. 33.2 pg/ml, P < 0.001) and LVMI (113 ± 25 vs. 102 ± 26 g/m², P < 0.001) were higher in PA patients than in EH patients. Moreover, the median NT-proBNP level was higher in APA patients than in IHA patients (68.0 vs. 42.4 pg/ml, P < 0.001). In stepwise multivariate regression analysis, LVMI was correlated with NT-proBNP, nighttime systolic BP and sex in PA patients.

CONCLUSIONS

Patients with PA show higher nighttime BP and NT-proBNP levels and lower nocturnal BP decline than those with EH. In addition, higher nocturnal systolic BP has been shown to be strongly associated with cardiac damage in PA patients.

Regression of left ventricular hypertrophy in primary aldosteronism after adrenalectomy: a meta-analysis of echocardiographic studies

AIM

Available evidence on regression of left ventricular (LV) hypertrophy in patients with primary aldosteronism after unilateral adrenalectomy is scanty. We performed a systematic meta-analysis of echocardiographic studies to provide an updated and comprehensive information on this issue.

METHODS

The PubMed, OVID-MEDLINE and Cochrane library databases were analyzed to search English-language articles published from 1 January 1990 up to 30 June 2020. Studies were identified by using MeSH terms and crossing the following search items: 'primary aldosteronism' 'Conn's syndrome' 'adrenalectomy', with 'cardiac damage', 'hypertensive heart disease' 'left ventricular mass', 'left ventricular hypertrophy', 'left ventricular hypertrophy regression', 'echocardiography'.

RESULTS

A total of 629 hypertensive patients with primary aldosteronism (mean age 49 years, 45% men) were included in 14 studies. Baseline and postintervention pooled mean LV mass/BSA values were 134 ± 4 and 108 ± 3 g/m2 [standard means difference (SMD) -0.42 ± 0.05, confidence interval (CI) -0.52/-0.32, P < 0.0001]; corresponding values for LV mass/h2.7 were 56 ± 2 and 49 ± 1 g/h2.7 (SMD -0.45 ± 0.06, CI -0.52/-0.36, P < 0.0001). Adrenalectomy, followed by a marked decrease in blood pressure, was associated with a decrease in relative wall thickness (SMD -0.17 ± 0.06, CI -0.31/-0.03, P < 0.01) as well as in the number of antihypertensive drugs (SMD -0.45 ± 0.04, CI -0.50-0.32, P < 0.0001).

CONCLUSION

The present meta-analysis suggests that adrenalectomy in patients with primary aldosteronism exerts a beneficial effect on LV structure and geometry by reducing the burden of LV hypertrophy and LV concentric geometry.

Preclinical cardiac disease in women and men with primary aldosteronism

PURPOSE

We tested the sex-specific associations between primary aldosteronism (PA), left ventricular (LV) hypertrophy and LV systolic myocardial function.

MATERIAL AND METHODS

Conventional and speckle tracking echocardiography was performed in 109 patients with PA and 89 controls with essential hypertension (EH). LV hypertrophy was identified if LV mass index exceeded 47.0 g/m^2.7 in women and 50.0 g/m^2.7 in men. LV systolic myocardial function was assessed by global longitudinal strain (GLS) and midwall shortening.

RESULTS

PA patients had higher prevalence of LV hypertrophy (52 vs. 21%, p < 0.001) than EH patients in both sexes, while GLS did not differ by sex or hypertension aetiology. In multivariable analyses, presence of LV hypertrophy was associated with PA and obesity in both sexes, while lower systolic myocardial function, whether measured by GLS or midwall shortening, was not associated with PA, but primarily with higher body mass index and LV mass index, respectively, in both sexes (all p < 0.05).

CONCLUSION

Having PA was associated with higher prevalence of LV hypertrophy both in women and men, compared to EH. PA was not associated with LV systolic myocardial function in either sex.

Myocardial mechano-energetic efficiency in primary aldosteronism

BACKGROUND

Available data indicate that patients with primary aldosteronism have an increased risk of cardiovascular events and cardiovascular risk seems to be, at least in part, independent of blood pressure (BP) values. Patients with primary aldosteronism have a greater prevalence of left ventricular (LV) hypertrophy and subtle alterations of ventricular function, which might contribute to the increase in cardiovascular risk. Recently, a noninvasive approach for the estimation of LV mechanical efficiency, obtained by echocardiography has been proposed.

AIM OF THE STUDY

To evaluate the determinants of myocardial mechanoenergetic efficiency index (MEEi), in a large group of patients with primary aldosteronism (n = 99) and in a control group of essential hypertensive patients (n = 99) matched for age, sex and BP values.

RESULTS

No differences between groups for age, sex, BMI, BP values, glucose, lipid profile and renal function were observed. LV mass index was greater in primary aldosteronism vs. essential hypertensive patients (46.0 ± 16.7 vs. 36.9 ± 8.6 g/m2, P < 0.001); also relative wall thickness was greater in primary aldosteronism (0.36 ± 0.1 vs. 0.32 ± 0.4, P < 0.001). Left atrial dimensions were significantly greater in primary aldosteronism. Ejection fraction was not different between groups, while endocardial and midwall fractional shortening were lower in primary aldosteronism vs. essential hypertensive patients (40 ± 7 vs. 43 ± 6, and 18 ± 3 vs. 21 ± 2, both P < 0.01). MEEi was lower in primary aldosteronism vs. essential hypertensive patients (0.44 ± 0.14 vs. 0.52 ± 0.10 ml/s per g, P < 0.01). A negative correlation was observed between MEEi and aldosterone levels (r = -0.203, P < 0.05) and aldosterone : renin ratio (P = -0.172, P < 0.05); the correlation remained significant after adjustment for possible confounders.

CONCLUSION

In patients with primary aldosteronism myocardial MEEi is lower as compared with essential hypertensive patients. A reduced MEEi may reflect an impairment of production and utilization of energy in the myocardium, which could lead to the occurrence of cardiovascular complications and therefore these findings may contribute to explain the increased risk of cardiovascular events in patients with primary aldosteronism.

Left ventricular remodeling and dysfunction in primary aldosteronism

Primary aldosteronism (PA) is a common cause of secondary hypertension and is associated with worse cardiovascular outcomes. The elevated aldosterone in PA leads to left ventricular (LV) remodeling and dysfunction. In recent decades, clinical studies have demonstrated worse LV remodeling including increased LV mass and cardiac fibrosis in patients with PA compared to patients with essential hypertension. Several mechanisms may explain the process of aldosterone-induced LV remodeling, including directly profibrotic and hypertrophic effects of aldosterone on myocardium, increased reactive oxygen species and profibrotic molecules, dysregulation of extracellular matrix metabolism, endothelium dysfunction and circulatory macrophages activation. LV remodeling causes LV diastolic and systolic dysfunction, which may consequently lead to clinical complications such as heart failure, atrial fibrillation, ischemic heart disease, and other vascular events. Adequate treatment with adrenalectomy or medical therapy can improve LV remodeling and dysfunction in PA patients. In this review, we discuss the mechanisms of aldosterone-induced LV remodeling and provide an up-to-date review of clinical research about LV remodeling-related heart structural changes, cardiac dysfunction, and their clinical impacts on patients with PA.

Nadir Aldosterone Levels After Confirmatory Tests Are Correlated With Left Ventricular Hypertrophy in Primary Aldosteronism

Left ventricular hypertrophy (LVH) is often seen in patients with primary aldosteronism (PA), and the prevalence of LVH is reportedly higher among patients with PA than patients with essential hypertension. However, the correlation between aldosterone levels and LVH is undefined, and how aldosterone affects LVH in patients with PA remains unclear. We, therefore, retrospectively assessed a large PA database established by the multicenter JPAS (Japan Primary Aldosteronism Study) to reveal the factors associated with LVH in patients with PA without suspected autonomous cortisol secretion. In the 1186 patients with PA studied, the basal plasma aldosterone concentration, plasma renin activity, and the aldosterone-to-renin ratio did not significantly correlate with left ventricular LV mass index (LVMI) in single or multiple regression analyses. However, the plasma aldosterone concentration after the captopril challenge test or saline-infusion test, which are associated with autonomous aldosterone secretion, correlated significantly with LVMI, even after adjusting for patients’ backgrounds, including age and blood pressure. In addition, hypokalemia and the unilateral subtype also correlated with LVMI. Longitudinal subanalysis of medically or surgically treated patients with PA showed significant reductions in LVMI in both the surgery (63.0±18.1 to 55.3±19.5 g/m 2.7 , P <0.001) and drug treatment (56.8±14.1 to 52.1±13.5 g/m 2.7 , P <0.001) groups. Our results suggest the autonomous aldosterone secretion level, not the basal aldosterone level itself, is relevant to LVH in patients with PA. In addition, the elevated LVMI seen in patients with PA is at least partially reversible with surgical or medical treatment.

A clinical prediction score using age at diagnosis and saline infusion test parameters can predict aldosterone-producing adenoma from idiopathic adrenal hyperplasia

PURPOSE

Accurate subtyping of the primary aldosteronism into aldosterone-producing adenoma (APA) and idiopathic adrenal hyperplasia (IAH) is important to direct for specific treatment modalities. The objective of the study was to compare the clinical and biochemical parameters of APA and IAH patients to derive a Clinical Prediction Score reliably predicting APA from IAH.

METHODS

This was a retrospective multi-centre study recruiting 38 APA patients and 42 IAH patients from four major hospitals in Hong Kong using database from Surgical Outcomes Monitoring and Improvement Programme and Clinical Data Analysis and Reporting System. Their clinical and biochemical parameters were evaluated.

RESULTS

Patients in APA group were younger than IAH group (mean age 48.6 ± 9.2 vs. 57.1 ± 7.3 years old, p < 0.001), had more suppressed renin before saline infusion in saline infusion test (SIT) (median 0.19 [IQR 0.15-0.37] vs. 0.39 [IQR 0.19-0.69] ng/mL/h, p = 0.01), and higher aldosterone level after saline infusion in SIT (median 674 [IQR 498-1000] vs. 327 [IQR 242-483] pmol/L, p < 0.001). A clinical prediction score using three parameters was devised, comprising age at diagnosis < 50 years, PRA before saline infusion in SIT ≤ 0.26 ng/mL/h, and aldosterone level after saline infusion in SIT ≥ 424 pmol/L. A score of 2 would predict APA with a sensitivity of 84.2% and specificity of 88.1%, and a score of 3 would predict APA with a sensitivity of 31.6% and specificity of 100%.

CONCLUSIONS

Clinical Prediction Score based on the combination of age at diagnosis, PRA, and aldosterone level in the saline infusion tests could reliably predict APA from IAH.

Associations Between Metabolic Profiles and Target-Organ Damage in Chinese Individuals With Primary Aldosteronism

Purpose: Patients with primary aldosteronism (PA) have an increased risk of target-organ damage (TOD), but whether metabolic syndrome (MetS) is more prevalent and contributes to TOD in PA patients remains unresolved. We aimed to evaluate the associations between MetS profiles and TOD in Chinese PA individuals. Methods: Metabolic parameters and pre-clinical TOD including left ventricular hypertrophy, estimated glomerular filtration, and microalbuminuria; insulin sensitivity or resistance; and islet β-cell function were assessed by the homeostasis models (HOMA-IR, HOMA-β) and the other surrogate indexes [composite insulin sensitivity index (ISI), modified β-cell function index (MBCI)] determined from the oral glucose tolerance test were compared in PA vs. matched essential hypertension (EH) patients. Results: A total of 109 PA patients and 109 essential hypertension (EH) controls individually matched for sex, age, and office systolic blood pressure and duration of hypertension were studied. The prevalence of MetS and its individual components in PA was significantly lower than in EH [MetS: 28 (25.6%) vs. 54 (49.5%), P < 0.001]. PA patients had a higher composite ISI but a lower HOMA-IR, HOMA-β, and MBCI than EH controls (all P < 0.05). Concerning TOD, PA patients had significantly higher prevalence of microalbuminuria and left ventricular hypertrophy (LVH), and lower levels of estimated glomerular filtration (eGFR) than EH controls (all P < 0.05). On multivariate logistic regression analysis, female gender and elevated plasma aldosterone levels were significantly associated with TOD in PA. However, there were no significant associations between MetS and its individual components and TOD in PA patients. Conclusions: PA patients had a lower MetS prevalence but exhibited more severe TOD than matched EH controls. The study highlights the deleterious effects of aldosterone excess on the development of TOD, whereas MetS or its individual components might be less influential in PA.

Left Ventricular Dysfunction in Patients With Primary Aldosteronism: A Propensity Score-Matching Follow-Up Study With Tissue Doppler Imaging

Background

Primary aldosteronism is the most common cause of secondary hypertension and is associated with left ventricular hypertrophy. However, whether aldosterone excess is responsible for left ventricular (LV) diastolic dysfunction is unknown.

Methods and Results

We prospectively enrolled 129 patients with aldosterone‐producing adenoma and 120 patients with essential hypertension, and analyzed their clinical, biochemical, and echocardiographic data, including tissue Doppler images. The patients with aldosterone‐producing adenoma were reevaluated 1 year after adrenalectomy. After propensity score matching, there were 105 patients in each group. The patients with aldosterone‐producing adenoma had worse diastolic function than the patients with essential hypertension, as reflected by lower e′ (P<0.001) and higher E/e′ (P=0.003). Multivariate analysis showed that LV diastolic function was significantly correlated with age (P<0.001), sex (P<0.001), body mass index (P=0.002), systolic blood pressure (P=0.004), creatinine (P=0.008), and log‐transformed aldosterone‐renin ratio (P=0.003). After adrenalectomy, the patients with aldosterone‐producing adenoma had significant improvements in LV diastolic function as reflected by an increase in e′ (P=0.003) and decrease in E/e′ (P=0.002). The change in E/e′ was independently correlated with baseline E/e′ (P<0.001) and change in LV mass index (P=0.006).

Conclusions

The patients with primary aldosteronism had worse LV diastolic function than the patients with essential hypertension after propensity score matching, and this could be reversed after adrenalectomy, suggesting that aldosterone excess may induce LV diastolic dysfunction.

Aldosterone induces left ventricular subclinical systolic dysfunction: a strain imaging study

BACKGROUND

Primary aldosteronism is associated with a higher incidence of left ventricular (LV) hypertrophy and diastolic dysfunction than essential hypertension. However, systolic function via endocardial measurements is similar between patients with primary aldosteronism and essential hypertension. Speckle-tracking echocardiography is a sensitive tool which can detect subclinical impairments in systolic function. The aim of this study was to investigate aldosterone-induced subclinical impairments in systolic function.

METHODS

We prospectively enrolled patients with primary aldosteronism and essential hypertension and analyzed their clinical data, biochemical data, and echocardiographic parameters, including myocardial strain [global longitudinal strain (GLS)].

RESULTS

Thirty-six patients with primary aldosteronism and 31 patients with essential hypertension were enrolled for analysis. The patients with primary aldosteronism had significantly lower serum potassium levels, lower plasma renin activity, higher aldosterone-to-renin ratio (ARR), and higher 24-h urinary aldosterone levels than patients with essential hypertension. With regards to echocardiographic parameters, the patients with primary aldosteronism had a thicker ventricular wall and higher LV mass index than those with essential hypertension. Most importantly, we found significant degradation of GLS in the patients with primary aldosteronism compared with those with essential hypertension (-17.84 ± 2.36 vs. -20.13 ± 2.32, P < 0.001). In correlation analysis, GLS was significantly correlated with serum potassium level, LV mass index, log-transformed plasma renin activity, log-transformed ARR, and log-transformed 24-h urinary aldosterone levels (all P < 0.05). Multivariate linear regression analysis further identified log-transformed ARR (β = 0.771, 95% confidence interval: 0.011-1.530, P = 0.047), and log-transformed 24-h urinary aldosterone level (β = 1.765, 95% confidence interval: 0.01-3.529, P = 0.050) as independent factors correlated with GLS.

CONCLUSION

Patients with primary aldosteronism have a lower magnitude of GLS than patients with essential hypertension, suggesting that aldosterone induces a subclinical decline in LV systolic function.

Decreased serum potassium may disturb sleep homeostasis in essential hypertensives

The aim is to investigate the association between alterations in the serum potassium (K+) concentration and sleep architecture parameters in essential hypertensives. Two hundred ninety-two hypertensives undergoing polysomnography and providing blood samples were recruited. The sleep architecture was composed of sleep stages 1 (N1), 2 (N2), 3 (N3), 4 (N4) and REM. The light sleep stage (LST) was composed of N1 + N2, and the deep sleep stage (DST) was composed of N3 + N4. The potentialrelationships between electrolytes and sleep parameters were determined via univariate and multivariate analyses. The subjects were divided into two groups via the serum K⁺ median (3.86 mmol/L). The K⁺ < 3.86 mmol/L group showed significantly decreased N1 (7.10 ± 4.55% vs 8.61 ± 5.23%, p = 0.002), LST (71.48 ± 11.33% vs 75.92 ± 17.08%, p = 0.013), and periodic leg movement during sleep related to microarousals (MA) /arousal (PLMS-A) [4 (1~10) vs 8 (3~15)/night, p < 0.001] and increased REM (17.38 ± 6.43% vs 15.37 ± 6.18%, p = 0.007) compared to the K⁺ ≥ 3.86 mmol/L group. A subdivided analysis by gender showed that these changes were more statistically significant in men than in women. Significant positive correlations were identified between K⁺ and N1 (r = 0.169, p = 0^.004), as well as PLMS-A (r = 0.222, p < 0.001) in subjects. Compared to women, a significantly strong correlation was identified between K+ and REM sleep in men (r = 0.158, p = 0.028 vs. r = 0.078, p = 0.442). Multiple linear regression analysis indicated that K+ is significantly associated with N1 in all subjects (p = 0.03) and with REM in men (p = 0.008), even after adjusting for confounders. Decreased K+ may disturb the homeostasis of the sleep architecture, and gender may interfere with their links in the hypertensive population.

Predictors of confirmatory test results for the diagnosis of primary hyperaldosteronism in hypertensive patients with an aldosterone-to-renin ratio greater than 20. The SHRIMP study

It remains unknown which surrogate markers can predict diagnostic test results for primary hyperaldosteronism (PA). The Secondary Hypertension Registry Investigation in Mie Prefecture (SHRIMP) study has sequentially and prospectively recruited 128 patients with hypertension with an aldosterone-to-renin ratio (ARR) greater than 20, evaluated the differences among essential hypertension (EHT), idiopathic hyperaldosteronism (IHA), and aldosterone-producing adenoma (APA), and analyzed the predictors for the confirmatory tests. The patients underwent saline-loading, captopril-challenge, and upright furosemide-loading tests. Carotid, renovascular, and cardiac echography, brachial ankle pulse wave velocity (baPWV), endothelial function, nocturnal blood pressure decline, and the apnea hypopnea index were evaluated. Multivariate regression analyses showed that the plasma aldosterone concentration (PAC) at screening was a strong predictor of the saline and captopril test results. The plasma renin activity (PRA) at screening, urine β2-microglobulin, and left ventricular mass index (LVMI) were independent predictors for the captopril test. The estimated saline PAC and captopril 60 and 90 min ARRs predicted by the equations were highly correlated with the real values. The ROC curve analysis showed PAC at screening among each of predictors for the diagnostic tests and PAC after the saline-loading test had the highest diagnostic abilities of APA. Patients with IHA were older and had glucose intolerance and increased U-Alb/gCre and resistive indices. In patients with APA, the levels of U-Alb/gCre and urine β2-microglobulin were increased, and levels of insulin and the HOMA-IR were decreased. In conclusion, our proposed equations may be useful for estimating saline PAC and captopril ARR. Diagnostic predictors may differ for each confirmatory test.

Microvascular endothelial function is impaired in patients with idiopathic hyperaldosteronism

The aims were to evaluate the relationship between idiopathic hyperaldosteronism (IHA) and grade of vascular function in the macrovasculature and microvasculature. Vascular function, including reactive hyperemia index (RIH), flow-mediated vasodilation (FMD), and nitroglycerine-induced vasodilation (NID) were evaluated in 52 patients with IHA, 53 patients with aldosterone-producing adenoma (APA), and 52 age-, sex-, and blood pressure-matched patients with essential hypertension (EHT). Log RHI was lower in the IHA and APA groups than in the EHT group (0.54 ± 0.25 and 0.55 ± 0.23 versus 0.79 ± 0.28; P < 0.01, respectively). FMD was lower in the APA group than in the EHT group (3.4 ± 2.1% versus 4.8 ± 2.8%; P = 0.02), whereas there was no significant difference in FMD between the IHA and the APA and EHT groups. NID was lower in the APA group than in the EHT group (10.0 ± 4.5% versus 12.5 ± 5.7%; P = 0.03), whereas there was no significant difference in NID between the IHA, APA, and EHT groups. Multiple regression analysis revealed an association of log RHI with plasma aldosterone concentration (t = -2.24; P = 0.03) and an association of FMD with plasma aldosterone concentration (t = -3.07; P < 0.01). Microvascular endothelial function was impaired in patients with IHA compared with that in patients with EHT.