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Pintus G, Seccia TM, Amar L, Azizi M, Riester A, Reincke M, Widimský J, Naruse M, Kocjan T, Negro A, Kline G, Tanabe A, Satoh F, Rump LC, Vonend O, Fuller PJ, Yang J, Chee NYN, Magill SB, Shafigullina Z, Quinkler M, Oliveras A, Lee BC, Chang CC, Wu VC, Krátká Z, Battistel M, Bagordo D, Caroccia B, Ceolotto G, Rossitto G, Rossi GP. Subtype Identification of Surgically Curable Primary Aldosteronism During Treatment With Mineralocorticoid Receptor Blockade. Hypertension 2024; 81:1391-1399. [PMID: 38525605 PMCID: PMC11095898 DOI: 10.1161/hypertensionaha.124.22721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/19/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND Current guidelines and consensus documents recommend withdrawal of mineralocorticoid receptor antagonists (MRAs) before primary aldosteronism (PA) subtyping by adrenal vein sampling (AVS), but this practice can cause severe hypokalemia and uncontrolled high blood pressure. Our aim was to investigate if unilateral PA can be identified by AVS during MRA treatment. METHODS We compared the rate of unilateral PA identification between patients with and without MRA treatment in large data sets of patients submitted to AVS while off renin-angiotensin system blockers and β-blockers. In sensitivity analyses, the between-group differences of lateralization index values after propensity score matching and the rate of unilateral PA identification in subgroups with undetectable (≤2 mUI/L), suppressed (<8.2 mUI/L), and unsuppressed (≥8.2 mUI/L) direct renin concentration levels were also evaluated. RESULTS Plasma aldosterone concentration, direct renin concentration, and blood pressure values were similar in non-MRA-treated (n=779) and MRA-treated (n=61) patients with PA, but the latter required more antihypertensive agents (P=0.001) and showed a higher rate of adrenal nodules (82% versus 67%; P=0.022) and adrenalectomy (72% versus 54%; P=0.01). However, they exhibited no significant differences in commonly used AVS indices and the area under the receiving operating characteristic curve of lateralization index, both under unstimulated conditions and postcosyntropin. Several sensitivity analyses confirmed these results in propensity score matching adjusted models and in patients with undetectable, or suppressed or unsuppressed renin levels. CONCLUSIONS At doses that controlled blood pressure and potassium levels, MRAs did not preclude the identification of unilateral PA at AVS. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01234220.
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Affiliation(s)
- Giovanni Pintus
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
- Department of Translational Medicine, Sapienza University of Rome, Italy (G.P.)
| | - Teresa Maria Seccia
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
| | - Laurence Amar
- Université Paris Cité, Institut national de la santé et de la recherche médicale (INSERM) UMRS 970 and CIC1418, France (L.A., M.A.)
- Assistance Publique-Hopitaux De Paris Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France (L.A., M.A.)
| | - Michel Azizi
- Université Paris Cité, Institut national de la santé et de la recherche médicale (INSERM) UMRS 970 and CIC1418, France (L.A., M.A.)
- Assistance Publique-Hopitaux De Paris Hôpital Européen Georges Pompidou, Hypertension Unit, Paris, France (L.A., M.A.)
| | - Anna Riester
- Department of Medicine IV, Ludwig Maximilian University of Munich (LMU) University Hospital, LMU Munich (A.R., M.R.)
| | - Martin Reincke
- Department of Medicine IV, Ludwig Maximilian University of Munich (LMU) University Hospital, LMU Munich (A.R., M.R.)
| | - Jiří Widimský
- 3 Department of Medicine (J.W., Z.K.), 1 Faculty of Medicine and General University Hospital, Prague, Czech Republic
- Department of Endocrinology and Metabolism (J.W., Z.K.), 1 Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Mitsuhide Naruse
- Department of Endocrinology, Clinical Research Institute, National Hospital Organization Kyoto Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Japan (M.N.)
| | - Tomaz Kocjan
- University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Slovenia (T.K.)
| | - Aurelio Negro
- Internal Medicine and Hypertension Center, Ospedale Sant’Anna di Castelnovo Ne’ Monti (A.N.)
- Azienda Unità sanitaria locale - Istituti di Ricovero e Cura a Carattere Scientifico - (ULS-IRCCS) di Reggio Emilia, Italy (A.N.)
| | - Gregory Kline
- University of Calgary, Foothills Medical Centre, Canada (G.K.)
| | - Akiyo Tanabe
- Department of Diabetes, Endocrinology and Metabolism, National Center for Global Health and Medicine, Tokyo, Japan (A.T.)
| | - Fumitoshi Satoh
- Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai (F.S.)
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Oliver Vonend
- Department of Nephrology, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany (L.C.R., O.V.)
| | - Peter J. Fuller
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | - Jun Yang
- Monash Health, Clayton, VIC, Australia (P.J.F., J.Y., N.Y.N.C.)
| | | | - Steven B. Magill
- Medical College of Wisconsin, Endocrinology Center, North Hills Health Center, Menomonee Falls, WI (S.B.M.)
| | - Zulfiya Shafigullina
- Department of Endocrinology, North-Western State Medical University named after I.I. Mechnikov, St. Petersburg, Russia (Z.S.)
| | | | - Anna Oliveras
- Hypertension Unit, Nephrology Department, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain (A.O.)
| | - Bo-Ching Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei (B.-C.L., C.-C.C.)
| | - Chin-Chen Chang
- Department of Medical Imaging, National Taiwan University Hospital, Taipei (B.-C.L., C.-C.C.)
- National Taiwan University College of Medicine, Taipei (C.-C.C.)
| | - Vin-Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan (V.-C.W.)
| | - Zuzana Krátká
- 3 Department of Medicine (J.W., Z.K.), 1 Faculty of Medicine and General University Hospital, Prague, Czech Republic
- Department of Endocrinology and Metabolism (J.W., Z.K.), 1 Faculty of Medicine and General University Hospital, Prague, Czech Republic
| | - Michele Battistel
- Hypertension Unit, Nephrology Department, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain (A.O.)
| | - Domenico Bagordo
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
| | - Brasilina Caroccia
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
| | - Giulio Ceolotto
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
| | - Giacomo Rossitto
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
| | - Gian Paolo Rossi
- Internal Emergency Medicine Unit, Department of Medicine, Specialized Center for Blood Pressure Disorders-Regione Veneto (G.P., T.M.S., D.B., B.C., G.C., G.R., G.P.R.), University of Padova, Italy
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Hua Y, He Q. Comparison between screening for primary aldosteronism with and without drug adjustment. Blood Press 2024; 33:2350981. [PMID: 38824645 DOI: 10.1080/08037051.2024.2350981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 04/29/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVE Few studies have evaluated the performance of non-drug-adjusted primary aldosteronism (PA) screening. Therefore, we aimed to examine the consistency between PA screening results with and without drug adjustment and to explore the effectiveness of screening without drug adjustment. METHODS This prospective study included 650 consecutive patients with a high risk of incidence PA. Patients who initially screened positive underwent rescreening with drug adjustments and confirmatory tests. Regarding the remaining patients, one of every three consecutive patients underwent rescreening with drug adjustments and confirmatory tests. The changes in aldosterone and renin concentrations were compared between patients with essential hypertension (EH) and those with PA before and after drug adjustment. Sensitivity and specificity were used to assess the diagnostic performance of screening without drug adjustment, using the confirmatory test results as the reference. RESULTS We screened 650 patients with hypertension for PA. Forty-nine patients were diagnosed with PA and 195 with EH. Regarding drugs, 519 patients were taking angiotensin-converting enzyme inhibitors (ACEIs), angiotensin II receptor blockers (ARBs), calcium channel blockers (CCBs), or diuretics alone or in combination. Forty-one patients were taking beta-blockers. Ninety patients were taking beta-blockers in combination with other drugs. In patients treated with ACEIs, ARBs, CCBs, or diuretics alone, or in combination, or beta-blockers alone, PA positivity was determined using the criteria, aldosterone-to-renin ratio (ARR) >38 pg/mL/pg/mL and plasma aldosterone concentration (PAC) >100 pg/mL, and negativity, using the criteria, ARR <9 pg/mL/pg/mL; the sensitivity and specificity were 94.7% and 94.5%, respectively. After drug adjustment, the sensitivity and specificity of screening were 92.1% and 89%, respectively. CONCLUSIONS In patients not treated with beta-blockers combined with others, when ARR >38 pg/mL/pg/mL and plasma aldosterone concentration (PAC) >100 pg/mL, or, ARR <9 pg/mL/pg/mL, non-drug-adjusted screening results were identical to with drug adjustment. Non-drug-adjusted screening could reduce the chance of medication adjustment, enable patients to continue their treatments and avoiding adverse effects, is of clinical importance.
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Affiliation(s)
- Yanlong Hua
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
| | - Qing He
- Department of Endocrinology and Metabolism, Tianjin Medical University General Hospital, Tianjin, China
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Lu JY, Chang YY, Lee TW, Wu MH, Chen ZW, Huang YT, Lai TS, Er LK, Lin YH, Wu VC, Cheng HM, Kao HL, Jia-Yin Hou C, Wu KD, Chen ST, Liu FH. How should anti-hypertensive medications be adjusted before screening for primary aldosteronism? J Formos Med Assoc 2024; 123 Suppl 2:S91-S97. [PMID: 37291044 DOI: 10.1016/j.jfma.2023.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/17/2023] [Accepted: 05/21/2023] [Indexed: 06/10/2023] Open
Abstract
Anti-hypertensive medications may affect plasma renin activity and/or plasma aldosterone concentration, misleading the interpretation of the aldosterone-to-renin ratio when screening for primary aldosteronism. The Task Force of Taiwan PA recommends that, when necessary, using α-adrenergic receptor blocking agents, centrally acting α-adrenergic agonists, and/or non-dihydropyridine calcium channel blockers should be considered to control blood pressure before screening for PA. We recommend temporarily holding β-adrenergic receptor blocking agents, mineralocorticoid receptor antagonists, dihydropyridine calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and all diuretics before screening for PA. Further large-scale randomized controlled studies are required to confirm the recommendations.
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Affiliation(s)
- Jin-Ying Lu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Yi-Yao Chang
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan.
| | - Ting-Wei Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Endocrinology and Metabolism, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.
| | - Ming-Hsien Wu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan; Division of Endocrinology and Metabolism, Department of Internal Medicine, New Taipei Municipal TuCheng Hospital (built and Operated by Chang Gung Medical Foundation), New Taipei City, Taiwan.
| | - Zheng-Wei Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin, Taiwan.
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan.
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Primary Aldosteronism Center at National Taiwan University Hospital, Taipei, Taiwan.
| | - Leay Kiaw Er
- The Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan; School of Medicine, Tzu-Chi University, Hualien, Taiwan.
| | - Yen-Hung Lin
- Primary Aldosteronism Center at National Taiwan University Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Primary Aldosteronism Center at National Taiwan University Hospital, Taipei, Taiwan.
| | - Hao-Min Cheng
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Institute of Public Health, National Yang Ming Chiao Tung University College of Medicine, Taipei, Taiwan; Center for Evidence-based Medicine, Taipei Veterans General Hospital, Taiwan.
| | - Hsien-Li Kao
- Division of Cardiology, Department of Internal Medicine and Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan.
| | | | - Kwan-Dun Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Szu-Tah Chen
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan.
| | - Feng-Hsuan Liu
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Brum de Sousa E, do Mar Menezes M, Cordeiro AM. A Case Report of Primary Aldosteronism and Extensive Hypertension-Mediated Organ Damage. Cureus 2024; 16:e53818. [PMID: 38465123 PMCID: PMC10924221 DOI: 10.7759/cureus.53818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 03/12/2024] Open
Abstract
Primary aldosteronism, the most common curable form of secondary hypertension, is associated with greater hypertension-related organ damage and cardiovascular complications compared to primary essential hypertension. The authors present a case involving a 41-year-old Black male admitted to the emergency department with left hemiparesis and blurred vision persisting for one hour, accompanied by markedly elevated blood pressure (220/140 mmHg). The patient was asymptomatic by then, and, aside from a history of tobacco smoking and occasional cannabis use, lacked significant medical comorbidities. Further investigations revealed a right acute hemorrhagic stroke, bilateral grade 4 hypertensive retinopathy, chronic kidney disease with end-stage renal disease, hypokalemia, and an elevated aldosterone/renin ratio. An abdominal CT scan showed bilateral adrenal hyperplasia. The patient was diagnosed with primary aldosteronism with extensive hypertension-mediated organ damage. This case highlights the significant harm caused by undiagnosed primary aldosteronism-induced secondary hypertension, emphasizing the importance of timely diagnosis and intervention to prevent organ damage.
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Affiliation(s)
- Elisabete Brum de Sousa
- Internal Medicine, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário Lisboa Central, Lisboa, PRT
| | - Maria do Mar Menezes
- Nephrology, Hospital Curry Cabral, Centro Hospitalar Universitário Lisboa Central, Lisboa, PRT
| | - Ana Maria Cordeiro
- Radiology, Hospital de Santo António dos Capuchos, Centro Hospitalar Universitário Lisboa Central, Lisboa, PRT
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Torresan F, Rossi FB, Zanin S, Caputo I, Caroccia B, Iacobone M, Rossi GP. Water and Electrolyte Content in Salt-Dependent HYpertension in the SKIn (WHYSKI): Effect of Surgical Cure of Primary Aldosteronism. High Blood Press Cardiovasc Prev 2024; 31:15-21. [PMID: 38123759 PMCID: PMC10925570 DOI: 10.1007/s40292-023-00614-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
INTRODUCTION: This study will test the hypothesis that primary aldosteronism (PA) involves alterations in Na+, K+, and water content in the skin that are corrected by adrenalectomy. AIM AND METHODS In skin biopsies, we will measure the content of Na+, K+, water, by physical-chemical methods and the osmotic-stress-responsive transcription factor Tonicity-responsive Enhancer Binding Protein (TonEBP, NFAT5) mRNA copy number by droplet digital PCR, in sex-balanced cohorts of 18 -75-year-old consecutive consenting patients with unilateral and bilateral PA, primary (essential) hypertension, and normotension. Before surgery, the patients with unilateral PA will receive the mineralocorticoid receptor antagonist (MRA) canrenone at doses that correct hypokalemia and high blood pressure values. They will be reassessed in an identical way one month after surgical cure, while off MRA. PA patients not selected for adrenalectomy will similarly be assessed at diagnosis and follow-up while on stable MRA treatment. Since a pilot study showed a direct correlation of dry weight (DW) with skin electrolytes and water content and significant differences of biopsy DW between surgery and follow-up, meaningful comparison of the skin cations and water content and TonEBP mRNA copy number, between specimen obtained at different time points, will require DW- and total mRNA-adjustment, respectively. CONCLUSION This study will provide novel information on the skin Na+, K+ and water content in PA, the paradigm of salt-dependent hypertension, and novel knowledge on the effect of surgical cure of hyperaldosteronism. The TonEBP-mediated regulation of Na+, K+ and water content in the skin will also be unveiled. TRAIL REGISTRY Trial Registration number: NCT06090617. Date of Registration: 2023-10-19.
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Affiliation(s)
- Francesca Torresan
- Endocrine Surgery Unit, Department of Surgery, Oncology, and Gastroenterology, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Federico Bernardo Rossi
- Internal and Emergency Unit and Specialized Hypertension Centre, Department of Medicine-DIMED, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Sofia Zanin
- Laboratory for Genetics of Mithocondrial Disorders, Imagine Institute, Université Paris Cité, Bd du Montparnasse, 24, 75015, Paris, France
| | - Ilaria Caputo
- Internal and Emergency Unit and Specialized Hypertension Centre, Department of Medicine-DIMED, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Brasilina Caroccia
- Internal and Emergency Unit and Specialized Hypertension Centre, Department of Medicine-DIMED, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology, and Gastroenterology, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy
| | - Gian Paolo Rossi
- Internal and Emergency Unit and Specialized Hypertension Centre, Department of Medicine-DIMED, University Hospital, University of Padua, Via Giustiniani, 2, 35128, Padua, Italy.
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Faconti L, Kulkarni S, Delles C, Kapil V, Lewis P, Glover M, MacDonald TM, Wilkinson IB. Diagnosis and management of primary hyperaldosteronism in patients with hypertension: a practical approach endorsed by the British and Irish Hypertension Society. J Hum Hypertens 2024; 38:8-18. [PMID: 37964158 PMCID: PMC10803267 DOI: 10.1038/s41371-023-00875-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/03/2023] [Accepted: 10/30/2023] [Indexed: 11/16/2023]
Abstract
Alongside the lack of homogeneity among international guidelines and consensus documents on primary hyperaldosteronism, the National UK guidelines on hypertension do not provide extensive recommendations regarding the diagnosis and management of this condition. Local guidelines vary from area to area, and this is reflected in the current clinical practice in the UK. In an attempt to provide support to the clinicians involved in the screening of subjects with hypertension and clinical management of suspected cases of primary hyperaldosteronism the following document has been prepared on the behalf of the BIHS Guidelines and Information Service Standing Committee. Through remote video conferences, the authors of this document reviewed an initial draft which was then circulated among the BIHS Executive members for feedback. A survey among members of the BIHS was carried out in 2022 to assess screening strategies and clinical management of primary hyperaldosteronism in the different regions of the UK. Feedback and results of the survey were then discussed and incorporated in the final document which was approved by the panel after consensus was achieved considering critical review of existing literature and expert opinions. Grading of recommendations was not performed in light of the limited available data from properly designed randomized controlled trials.
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Affiliation(s)
- Luca Faconti
- King's College London British Heart Foundation Centre, Department of Clinical Pharmacology, 4th Floor, North Wing, St. Thomas' Hospital, Westminster Bridge, London, SE17EH, UK.
| | - Spoorthy Kulkarni
- Cambridge University hospitals NHS foundation trust, Cambridge United Kingdom (S.K.), Cambridge, UK
| | - Christian Delles
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, G12 8TA, UK
| | - Vikas Kapil
- William Harvey Research Institute, Centre for Cardiovascular Medicine and Devices, Queen Mary University London, London, EC1M 6BQ, UK
- Barts BP Centre of Excellence, Barts Heart Centre, London, EC1A 7BE, UK
| | - Philip Lewis
- Department of Cardiology, Stockport NHS Foundation Trust, Stockport, UK
| | - Mark Glover
- Deceased, formerly Division of Therapeutics and Molecular Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Thomas M MacDonald
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Ian B Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, Department of Medicine, University of Cambridge, Cambridge, UK
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Beger C, Karg T, Hinrichs JB, Ringe B, Haller H, Meyer BC, Limbourg FP. RAS-challenge as a first-look test for detection of primary aldosteronism in patients with treatment-resistant hypertension. Blood Press 2023; 32:2179340. [PMID: 36803263 DOI: 10.1080/08037051.2023.2179340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
PURPOSE Primary aldosteronism (PA), characterised by low-renin hypertension, confers a high cardiovascular risk and is the most common cause of secondary hypertension, with an increased prevalence in patients with treatment-resistant hypertension. However, it is estimated that only a small percentage of affected patients are identified in routine clinical practice. Inhibitors of the renin-angiotensin system cause an increase in renin levels in patients with intact aldosterone regulation, and inadequate low renin with concurrent RAS inhibition (RASi) may therefore indicate PA, which could serve as a first look screening test for selection for formal work-up. METHODS We analysed patients between 2016-2018 with treatment-resistant hypertension who had inadequate low renin in the presence of RASi (i. e. at risk for PA) and who were offered systematic work-up with adrenal vein sampling (AVS). RESULTS A total of 26 pts were included in the study (age 54.8 ± 11, male 65%). Mean office blood pressure (BP) was 154/95 mmHg on 4.5 antihypertensive drug classes. AVS had a high technical success rate (96%) and demonstrated unilateral disease in the majority of patients (57%), most of which (77%) were undetected by cross-sectional imaging. CONCLUSION In patients with resistant hypertension, low renin in the presence of RASi is a strong indicator for autonomous aldosterone secretion. It may serve as an on-medication screening test for PA to select for formal PA work up.
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Affiliation(s)
- Christian Beger
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Theresa Karg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Jan B Hinrichs
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Bastian Ringe
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Hermann Haller
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Bernhard C Meyer
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Florian P Limbourg
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
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Ha J, Park JH, Kim KJ, Kim JH, Jung KY, Lee J, Choi JH, Lee SH, Hong N, Lim JS, Park BK, Kim JH, Jung KC, Cho J, Kim MK, Chung CH. 2023 Korean Endocrine Society Consensus Guidelines for the Diagnosis and Management of Primary Aldosteronism. Endocrinol Metab (Seoul) 2023; 38:597-618. [PMID: 37828708 PMCID: PMC10765003 DOI: 10.3803/enm.2023.1789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 10/14/2023] Open
Abstract
Primary aldosteronism (PA) is a common, yet underdiagnosed cause of secondary hypertension. It is characterized by an overproduction of aldosterone, leading to hypertension and/or hypokalemia. Despite affecting between 5.9% and 34% of patients with hypertension, PA is frequently missed due to a lack of clinical awareness and systematic screening, which can result in significant cardiovascular complications. To address this, medical societies have developed clinical practice guidelines to improve the management of hypertension and PA. The Korean Endocrine Society, drawing on a wealth of research, has formulated new guidelines for PA. A task force has been established to prepare PA guidelines, which encompass epidemiology, pathophysiology, clinical presentation, diagnosis, treatment, and follow-up care. The Korean clinical guidelines for PA aim to deliver an evidence-based protocol for PA diagnosis, treatment, and patient monitoring. These guidelines are anticipated to ease the burden of this potentially curable condition.
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Affiliation(s)
- Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jung Hwan Park
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Kyoung Jin Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jung Hee Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyong Yeun Jung
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Han Choi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Seung Hun Lee
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Namki Hong
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Soo Lim
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Byung Kwan Park
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyeong Cheon Jung
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
| | - Jooyoung Cho
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Mi-kyung Kim
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Choon Hee Chung
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - The Committee of Clinical Practice Guideline of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - The Korean Adrenal Study Group of Korean Endocrine Society
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
- Division of Endocrinology and Metabolism, Department of Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Department of Internal Medicine, Endocrine Research Institute, Yonsei University College of Medicine, Seoul, Korea
- Department of Internal Medicine and Research Institute of Metabolism and Inflammation, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Departments of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul, Korea
- Department of Laboratory Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
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9
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Vaidya A, Hundemer GL, Nanba K, Parksook WW, Brown JM. Primary Aldosteronism: State-of-the-Art Review. Am J Hypertens 2022; 35:967-988. [PMID: 35767459 PMCID: PMC9729786 DOI: 10.1093/ajh/hpac079] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 06/15/2022] [Accepted: 06/27/2022] [Indexed: 12/15/2022] Open
Abstract
We are witnessing a revolution in our understanding of primary aldosteronism (PA). In the past 2 decades, we have learned that PA is a highly prevalent syndrome that is largely attributable to pathogenic somatic mutations, that contributes to cardiovascular, metabolic, and kidney disease, and that when recognized, can be adequately treated with widely available mineralocorticoid receptor antagonists and/or surgical adrenalectomy. Unfortunately, PA is rarely diagnosed, or adequately treated, mainly because of a lack of awareness and education. Most clinicians still possess an outdated understanding of PA; from primary care physicians to hypertension specialists, there is an urgent need to redefine and reintroduce PA to clinicians with a modern and practical approach. In this state-of-the-art review, we provide readers with the most updated knowledge on the pathogenesis, prevalence, diagnosis, and treatment of PA. In particular, we underscore the public health importance of promptly recognizing and treating PA and provide pragmatic solutions to modify clinical practices to achieve this.
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Affiliation(s)
- Anand Vaidya
- Department of Medicine, Center for Adrenal Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gregory L Hundemer
- Department of Medicine (Division of Nephrology) and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Kazutaka Nanba
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
- Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Wasita W Parksook
- Department of Medicine, Division of Endocrinology and Metabolism, and Division of General Internal Medicine, Faculty of Medicine, Chulalongkorn University, and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jenifer M Brown
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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10
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Mulatero P, Bertello C, Veglio F, Monticone S. Approach to the Patient on Antihypertensive Therapy: Screen for Primary Aldosteronism. J Clin Endocrinol Metab 2022; 107:3175-3181. [PMID: 35964152 DOI: 10.1210/clinem/dgac460] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Indexed: 11/19/2022]
Abstract
Primary aldosteronism (PA) is a condition that is still largely overlooked, resulting in a considerable burden of mortality and morbidity. This is despite decades of clinical and translational research on the deleterious effects of aldosterone on the cardiovascular system and the publication of several guidelines and consensuses on its diagnosis and treatment. One of the main reasons for the low rate of testing is the difficulty of screening patients on antihypertensive therapy that potentially interferes with aldosterone and renin levels and thus confound the interpretation of the aldosterone to renin ratio, the accepted and conventionally used screening test. To avoid interference, usually the therapies that affect the renin-angiotensin aldosterone system are withdrawn and substituted with noninterfering medications. However, in many cases the screening test can be confidently interpreted even when such therapies are not discontinued. In this review, we will evaluate the effects of antihypertensive therapies on the screening test for PA and suggest a practical approach for its interpretation.
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Affiliation(s)
- Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Chiara Bertello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, 10126, Torino, Italy
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11
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Abstract
Primary aldosteronism is a common cause of hypertension and is a risk factor for cardiovascular and renal morbidity and mortality, via mechanisms mediated by both hypertension and direct insults to target organs. Despite its high prevalence and associated complications, primary aldosteronism remains largely under-recognized, with less than 2% of people in at-risk populations ever tested. Fundamental progress made over the past decade has transformed our understanding of the pathogenesis of primary aldosteronism and of its clinical phenotypes. The dichotomous paradigm of primary aldosteronism diagnosis and subtyping is being redefined into a multidimensional spectrum of disease, which spans subclinical stages to florid primary aldosteronism, and from single-focal or multifocal to diffuse aldosterone-producing areas, which can affect one or both adrenal glands. This Review discusses how redefining the primary aldosteronism syndrome as a multidimensional spectrum will affect the approach to the diagnosis and subtyping of primary aldosteronism.
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Affiliation(s)
- Adina F Turcu
- Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
- Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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12
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Rossi GP, Rossitto G. Letter to the Editor From Paolo Rossi and Rossitto: "Mineralocorticoid Receptor Antagonist Effect on Aldosterone to Renin Ratio in Patients With Primary Aldosteronism". J Clin Endocrinol Metab 2022; 107:e892-e893. [PMID: 34610120 DOI: 10.1210/clinem/dgab717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Gian Paolo Rossi
- Emergency Medicine and Specialized Hypertension Center, Department of Medicine (DIMED), University of Padova, Padova, Italy
| | - Giacomo Rossitto
- Emergency Medicine and Specialized Hypertension Center, Department of Medicine (DIMED), University of Padova, Padova, Italy
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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13
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Primary Hyperaldosteronism: When to Suspect It and How to Confirm Its Diagnosis. ENDOCRINES 2022. [DOI: 10.3390/endocrines3010003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The definition of primary hyperaldosteronism (PA) has shifted, as progress has been made in understanding the disease. PA can be produced by unilateral or bilateral cortical adrenal hyperproduction of aldosterone, due to hyperplasia, aldosterone-secreting cell clusters, aldosterone-producing macro or micro adenoma/s, and combinations of the above, or by an aldosterone-producing carcinoma. PA is a highly prevalent disease, affecting close to 10% of the hypertensive population. However, PA is clearly underdiagnosed. The purpose of this review is to address current knowledge of PA’s clinical manifestations, as well as current methods of diagnosis. PA is associated with a higher cardiovascular morbidity and mortality than essential hypertension with similar blood pressure control. Young hypertensive patients, those with a first-degree relative with PA or ictus, and/or those with apnea/hypopnea syndrome, moderate/severe/resistant hypertension, adrenal incidentaloma, and/or hypokalemia should be screened for PA. PA can induce atrial fibrillation (AF), and those patients should also be screened for PA. We propose the use of the Captopril challenge test (CCT), oral salt loading, or intravenous salt loading for PA diagnosis, given their availability in the majority of hospital centers. CCT could be first-line, since it is safe and easy to perform.
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14
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Evans J, Ward J, Domenig O, Mochel JP, Creevy K. Suspected primary hyperreninism in a cat with malignant renal sarcoma and global renin-angiotensin-aldosterone system upregulation. J Vet Intern Med 2022; 36:272-278. [PMID: 34859924 PMCID: PMC8783369 DOI: 10.1111/jvim.16329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/14/2021] [Accepted: 11/17/2021] [Indexed: 12/01/2022] Open
Abstract
A 14-year-old male castrated domestic medium-hair cat with diabetes mellitus was evaluated for vomiting, diarrhea, and anorexia. Two weeks before presentation, the cat had been diagnosed with congestive heart failure and started on furosemide. Initial diagnostic testing identified hypokalemia, systemic hypertension, and hypertrophic cardiomyopathy phenotype, and plasma aldosterone concentration was moderately increased. Abdominal ultrasound examination disclosed bilateral adrenomegaly and a right renal mass, and cytology of a needle aspirate of the mass was consistent with malignant neoplasia. The cat was treated with amlodipine and spironolactone. Because of the unusual presentation for hyperaldosteronism, a comprehensive profile of renin-angiotensin-aldosterone system (RAAS) peptides was performed. Results from multiple timepoints indicated persistently and markedly increased plasma renin activity and generalized RAAS upregulation. In addition to the lack of adrenal tumor, the markedly increased plasma renin activity was atypical for primary hyperaldosteronism. These clinical findings are suggestive of primary hyperreninism, a condition previously unreported in cats. The concurrent presence of a renal neoplasm suggests the possibility of a renin-secreting tumor.
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Affiliation(s)
- Jeremy Evans
- Department of Small Animal Clinical SciencesTexas A&M College of Veterinary Medicine & Biomedical SciencesCollege StationTexasUSA
| | - Jessica Ward
- Veterinary Clinical SciencesIowa State University College of Veterinary MedicineAmesIowaUSA
| | | | - Jonathan P. Mochel
- Department of Biomedical Sciences, SMART PharmacologyIowa State UniversityAmesIowaUSA
| | - Kate Creevy
- Department of Small Animal Clinical SciencesTexas A&M College of Veterinary Medicine & Biomedical SciencesCollege StationTexasUSA
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15
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Ceccato F, Barbot M, Scaroni C, Boscaro M. Frequently asked questions and answers (if any) in patients with adrenal incidentaloma. J Endocrinol Invest 2021; 44:2749-2763. [PMID: 34160793 PMCID: PMC8572215 DOI: 10.1007/s40618-021-01615-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 06/14/2021] [Indexed: 12/20/2022]
Abstract
PURPOSE Adrenal incidentalomas (AIs) are incidentally discovered adrenal masses, during an imaging study undertaken for other reasons than the suspicion of adrenal disease. Their management is not a minor concern for patients and health-care related costs, since their increasing prevalence in the aging population. The exclusion of malignancy is the first question to attempt, then a careful evaluation of adrenal hormones is suggested. Surgery should be considered in case of overt secretion (primary aldosteronism, adrenal Cushing's Syndrome or pheochromocytoma), however the management of subclinical secretion is still a matter of debate. METHODS The aim of the present narrative review is to offer a practical guidance regarding the management of AI, by providing evidence-based answers to frequently asked questions. CONCLUSION The clinical experience is of utmost importance: a personalized diagnostic-therapeutic approach, based upon multidisciplinary discussion, is suggested.
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Affiliation(s)
- F Ceccato
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy.
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy.
- Department of Neuroscience DNS, University of Padova, Padova, Italy.
| | - M Barbot
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - C Scaroni
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - M Boscaro
- Endocrinology Unit, Department of Medicine DIMED, University of Padova, Via Ospedale Civile, 105-35128, Padova, Italy
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16
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Armanini D, Sabbadin C, Boscaro M. Primary aldosteronism: considerations about the evaluation of the aldosterone to renin ratio during canrenone treatment. J Endocrinol Invest 2021; 44:2009-2010. [PMID: 33454931 DOI: 10.1007/s40618-021-01500-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022]
Affiliation(s)
- D Armanini
- Department of Medicine (DIMED)-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy.
| | - C Sabbadin
- Department of Medicine (DIMED)-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy
| | - M Boscaro
- Department of Medicine (DIMED)-Endocrinology, University of Padua, Via Ospedale 105, 35128, Padua, Italy
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17
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Pecori A, Buffolo F, Burrello J, Mengozzi G, Rumbolo F, Avataneo V, D'Avolio A, Rabbia F, Bertello C, Veglio F, Mulatero P, Monticone S. Mineralocorticoid Receptor Antagonist Effect on Aldosterone to Renin Ratio in Patients With Primary Aldosteronism. J Clin Endocrinol Metab 2021; 106:e3655-e3664. [PMID: 33942084 DOI: 10.1210/clinem/dgab290] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Although current international guidelines recommend to avoid mineralocortcoid receptor antagonists in patients undergoing screening test for primary aldosteronism, a recent report suggested that mineralocorticoid receptor antagonist treatment can be continued without significant influence on screening results. OBJECTIVE We aimed to evaluate the effect of mineralocorticoid receptor antagonists on the aldosterone to renin ratio in patients with primary aldosteronism. METHODS We prospectively enrolled 121 patients with confirmed primary aldosteronism who started mineralocorticoid receptor antagonist (canrenone) treatment. Eighteen patients (11 with unilateral and 7 with bilateral primary aldosteronism) constituted the short-term study cohort and underwent aldosterone, renin, and potassium measurement after 2 and 8 weeks of canrenone therapy. The long-term cohort comprised 102 patients (16 with unilateral and 67 with bilateral primary aldosteronism, and 19 with undetermined subtype) who underwent hormonal and biochemical re-assessment after 2 to 12 months of canrenone therapy. RESULTS Renin and potassium levels showed a significant increase, and the aldosterone to renin ratio displayed a significant reduction compared with baseline after both a short- and long-term treatment. These effects were progressively more evident with higher doses of canrenone and after longer periods of treatment. We demonstrated that canrenone exerted a deep impact on the diagnostic accuracy of the screening test for primary aldosteronism: the rate of false negative tests was raised to 16.7%, 38.9%, 54.5%, and 72.5% after 2 weeks, 8 weeks, 2 to 6 months, and 7 to 12 months of mineralocorticoid receptor antagonist treatment, respectively. CONCLUSION Mineralocorticoid receptor antagonists should be avoided in patients with hypertension before measurement of renin and aldosterone for screening of primary aldosteronism.
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Affiliation(s)
- Alessio Pecori
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Fabrizio Buffolo
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Jacopo Burrello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Giulio Mengozzi
- Department of Laboratory Medicine, AOU Città della Salute e della Scienza, Turin, Italy
| | - Francesca Rumbolo
- Department of Laboratory Medicine, AOU Città della Salute e della Scienza, Turin, Italy
| | - Valeria Avataneo
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Antonio D'Avolio
- Laboratory of Clinical Pharmacology and Pharmacogenetics, Department of Medical Sciences, University of Torino, Amedeo di Savoia Hospital, Torino, Italy
| | - Franco Rabbia
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Chiara Bertello
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Franco Veglio
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Paolo Mulatero
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
| | - Silvia Monticone
- Division of Internal Medicine and Hypertension Unit, Department of Medical Sciences, University of Torino, Torino, Italy
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18
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Voltan G, Boscaro M, Armanini D, Scaroni C, Ceccato F. A multidisciplinary approach to the management of adrenal incidentaloma. Expert Rev Endocrinol Metab 2021; 16:201-212. [PMID: 34240680 DOI: 10.1080/17446651.2021.1948327] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 06/23/2021] [Indexed: 01/15/2023]
Abstract
An adrenal incidentaloma (AI) is an adrenal neoplasm incidentally discovered during an imaging unrelated to suspected adrenal disease. The aim of the present review is to offer practical guidance on the multidisciplinary approach of AIs.Areas covered:The prevalence of AI is high in the aging population (up to 5-8%); however, hormonally active or malignant conditions are rare. After the discovery of an AI, it is suggested to assess in parallel if the mass is potentially malignant and functionally active. The answer to the former question is mainly based on medical history (extra-adrenal malignancies, new-onset of signs or symptoms) and imaging (conventional radiology and/or nuclear medicine). The answer to the latter question is a complete endocrine evaluation of both cortical (glucocorticoids, mineralocorticoids) and medullary (catecholamines) secretion.Expert opinion:A multidisciplinary discussion is suggested for patients with adrenal disease, after the exclusion of nonfunctioning benign cortical adenoma, in order to plan a close and tailored follow-up for the suspected malignant or functioning forms. Surgery is advised for patients with malignant disease (adrenocortical cancer) or with clinically relevant secreting neoplasm (primary aldosteronism, Cushing's syndrome, and pheochromocytoma).
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Affiliation(s)
- Giacomo Voltan
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Marco Boscaro
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Decio Armanini
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
| | - Carla Scaroni
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
| | - Filippo Ceccato
- Endocrinology, Department of Medicine DIMED, University of Padova, Padova, Italy
- Endocrine Disease Unit, University-Hospital of Padova, Padova, Italy
- Department of Neuroscience DNS, University of Padova, Padova, Italy
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19
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Vidal-Petiot E. Editorial: Drug-resistant hypertension and primary aldosteronism. Eur J Prev Cardiol 2021; 29:e82-e84. [PMID: 34109384 DOI: 10.1093/eurjpc/zwaa124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Emmanuelle Vidal-Petiot
- Physiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, and Inserm U1149, Université de Paris, Paris, France
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20
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Jędrusik P, Symonides B, Lewandowski J, Gaciong Z. The Effect of Antihypertensive Medications on Testing for Primary Aldosteronism. Front Pharmacol 2021; 12:684111. [PMID: 34054559 PMCID: PMC8155700 DOI: 10.3389/fphar.2021.684111] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 04/30/2021] [Indexed: 11/13/2022] Open
Abstract
Primary aldosteronism (PA) is a potentially curable form of secondary hypertension caused by excessive renin-independent aldosterone secretion, leading to increased target organ damage and cardiovascular morbidity and mortality. The diagnosis of PA requires measuring renin and aldosterone to calculate the aldosterone-to-renin ratio, followed by confirmatory tests to demonstrate renin-independent aldosterone secretion and/or PA subtype differentiation. Various antihypertensive drug classes interfere with the renin-angiotensin-aldosterone axis and hence evaluation for PA should ideally be performed off-drugs. This is, however, often precluded by the risks related to suboptimal control of blood pressure and serum potassium level in the evaluation period. In the present review, we summarized the evidence regarding the effect of various antihypertensive drug classes on biochemical testing for PA, and critically appraised the issue whether and which antihypertensive medications should be withdrawn or, conversely, might be continued in patients evaluated for PA. The least interfering drugs are calcium antagonists, alpha-blockers, hydralazine, and possibly moxonidine. If necessary, the testing may also be attempted during treatment with beta-blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockers but renin and aldosterone measurements must be interpreted in the context of known effects of these drugs on these parameters. Views are evolving on the feasibility of testing during treatment with mineralocorticoid receptor antagonists, as these drugs are now increasingly considered acceptable in specific patient subsets, particularly in those with severe hypokalemia and/or poor blood pressure control on alternative treatment.
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Affiliation(s)
- Piotr Jędrusik
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Lewandowski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Zbigniew Gaciong
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
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21
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Chee MR, Hoo J, Libianto R, Gwini SM, Hamilton G, Narayan O, Young MJ, Fuller PJ, Yang J. Prospective Screening for Primary Aldosteronism in Patients With Suspected Obstructive Sleep Apnea. Hypertension 2021; 77:2094-2103. [PMID: 33896193 DOI: 10.1161/hypertensionaha.120.16902] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Min Ru Chee
- Department of Endocrinology (M.R.C., J.H., R.L., P.J.F., J.Y.), Monash Health, Clayton, Victoria, Australia.,Department of Medicine, School of Clinical Sciences (M.R.C., J.H., R.L., G.H., J.Y.), Monash University, Melbourne, Victoria, Australia
| | - Jesse Hoo
- Department of Endocrinology (M.R.C., J.H., R.L., P.J.F., J.Y.), Monash Health, Clayton, Victoria, Australia.,Department of Medicine, School of Clinical Sciences (M.R.C., J.H., R.L., G.H., J.Y.), Monash University, Melbourne, Victoria, Australia
| | - Renata Libianto
- Department of Endocrinology (M.R.C., J.H., R.L., P.J.F., J.Y.), Monash Health, Clayton, Victoria, Australia.,Department of Medicine, School of Clinical Sciences (M.R.C., J.H., R.L., G.H., J.Y.), Monash University, Melbourne, Victoria, Australia.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (R.L., M.J.Y., P.J.F., J.Y.)
| | - Stella M Gwini
- School of Public Health and Preventive Medicine (S.M.G.), Monash University, Melbourne, Victoria, Australia.,University Hospital Geelong, Barwon Health, Victoria, Australia (S.M.G.)
| | - Garun Hamilton
- Department of Lung and Sleep Medicine (G.H.), Monash Health, Clayton, Victoria, Australia.,Department of Medicine, School of Clinical Sciences (M.R.C., J.H., R.L., G.H., J.Y.), Monash University, Melbourne, Victoria, Australia
| | - Om Narayan
- MonashHeart (O.N.), Monash Health, Clayton, Victoria, Australia
| | - Morag J Young
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (R.L., M.J.Y., P.J.F., J.Y.).,Baker Heart and Diabetes Institute, Prahran, Australia (M.J.Y.)
| | - Peter J Fuller
- Department of Endocrinology (M.R.C., J.H., R.L., P.J.F., J.Y.), Monash Health, Clayton, Victoria, Australia.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (R.L., M.J.Y., P.J.F., J.Y.)
| | - Jun Yang
- Department of Endocrinology (M.R.C., J.H., R.L., P.J.F., J.Y.), Monash Health, Clayton, Victoria, Australia.,Department of Medicine, School of Clinical Sciences (M.R.C., J.H., R.L., G.H., J.Y.), Monash University, Melbourne, Victoria, Australia.,Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia (R.L., M.J.Y., P.J.F., J.Y.)
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22
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Rossi GP, Rossitto G, Amar L, Azizi M, Riester A, Reincke M, Degenhart C, Widimsky J, Naruse M, Deinum J, Schultze Kool L, Kocjan T, Negro A, Rossi E, Kline G, Tanabe A, Satoh F, Rump LC, Vonend O, Willenberg HS, Fuller PJ, Yang J, Chee NYN, Margill SB, Shafigullina Z, Quinkler M, Oliveras A, Lee BC, Wu VC, Kratka Z, Seccia TM, Lenzini L. Drug-resistant hypertension in primary aldosteronism patients undergoing adrenal vein sampling: the AVIS-2-RH study. Eur J Prev Cardiol 2021; 29:e85-e93. [PMID: 33742213 DOI: 10.1093/eurjpc/zwaa108] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/30/2020] [Accepted: 10/08/2020] [Indexed: 12/31/2022]
Abstract
AIMS We aimed at determining the rate of drug-resistant arterial hypertension in patients with an unambiguous diagnosis of primary aldosteronism (PA). Moreover, we sought for investigating the diagnostic performance of adrenal vein sampling (AVS), and the effect of adrenalectomy on blood pressure (BP) and prior treatment resistance in PA patients subtyped by AVS in major referral centres. METHODS AND RESULTS The Adrenal Vein Sampling International Study-2 (AVIS-2) was a multicentre international study that recruited consecutive PA patients submitted to AVS, according to current guidelines, during 15 years. The patients were over 18 years old with arterial hypertension and had an unambiguous diagnosis of PA. The rate of resistant hypertension was assessed at baseline and after adrenalectomy using the American Heart Association (AHA) 2018 definition. Information on presence or absence of resistant hypertension was available in 89% of the 1625 enrolled PA patients. Based on the AHA 2018 criteria, resistant hypertension was found in 20% of patients, of which about two-thirds (14%) were men and one-third (6%) women (χ2 = 17.1, P < 1*10-4) with a higher rate of RH in men than in women (23% vs. 15% P < 1*10-4). Of the 292 patients with resistant hypertension, 98 (34%) underwent unilateral AVS-guided adrenalectomy, which resolved BP resistance to antihypertensive treatment in all. CONCLUSIONS (i) Resistant hypertension is a common presentation in patients seeking surgical cure of PA; (ii) AVS is key for the optimal management of patients with PA due to resistant hypertension; and (iii) AVS-guided adrenalectomy allowed resolution of treatment-resistant hypertension.
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Affiliation(s)
- Gian Paolo Rossi
- Department of Medicine-DIMED, Emergency and Hypertension Unit, University of Padova, University Hospital, via Giustiniani, 2, 35126 Padova, Italy
| | - Giacomo Rossitto
- Department of Medicine-DIMED, Emergency and Hypertension Unit, University of Padova, University Hospital, via Giustiniani, 2, 35126 Padova, Italy.,Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Laurence Amar
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, F-75015 Paris, France.,Université de Paris, INSERM, CIC1418 and UMR 970, F-75015 Paris, France
| | - Michel Azizi
- AP-HP, Hôpital Européen Georges-Pompidou, Hypertension Department and DMU CARTE, F-75015 Paris, France.,Université de Paris, INSERM, CIC1418 and UMR 970, F-75015 Paris, France
| | - Anna Riester
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Martin Reincke
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Christoph Degenhart
- Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU München, München, Germany
| | - Jiri Widimsky
- 3rd Department of Medicine, Charles University Prague, General Hospital, Prague, Czech Republic
| | - Mitsuhide Naruse
- Clinical Research Institute of Endocrinology and Metabolic Diseases, National Hospital Organization Kyoto Medical Center and Endocrine Center, Ijinkai Takeda General Hospital, Kyoto, Japan
| | - Jaap Deinum
- Department of Internal Medicine, Radboud University Nijmegen, Nijmegen, Netherlands
| | - Leo Schultze Kool
- Department of Internal Medicine, Radboud University Nijmegen, Nijmegen, Netherlands
| | - Tomaz Kocjan
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Zaloska 7, 1525 Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana. Slovenia
| | - Aurelio Negro
- Department of Internal Medicine, Azienda Unità Sanitaria Locale, IRCCS Arcispedale S. Maria Nuova, Hypertension Unit, Reggio Emilia, Italy
| | - Ermanno Rossi
- Department of Internal Medicine, Azienda Unità Sanitaria Locale, IRCCS Arcispedale S. Maria Nuova, Hypertension Unit, Reggio Emilia, Italy
| | - Gregory Kline
- University of Calgary, Foothills Medical Centre, Calgary, Canada
| | - Akiyo Tanabe
- Institute of Clinical Endocrinology, Tokyo Women's Medical University, Tokyo, Japan
| | - Fumitoshi Satoh
- Department of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Hospital, Sendai, Japan
| | - Lars Christian Rump
- Department of Nephrology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany
| | - Oliver Vonend
- Department of Nephrology, Medical Faculty, Heinrich-Heine University, Düsseldorf, Germany.,Division of Endocrinology and Metabolism Rostock University Medical Center Ernst-Heydemann-Str. 6 18057 Rostock, Germany
| | - Holger S Willenberg
- Division of Endocrinology and Metabolism Rostock University Medical Center Ernst-Heydemann-Str. 6 18057 Rostock, Germany
| | - Peter J Fuller
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Jun Yang
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia.,Department of Medicine, Monash University, Clayton, Victoria, Australia
| | - Nicholas Yong Nian Chee
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Clayton, Victoria, Australia
| | - Steven B Margill
- Medical College of Wisconsin, Endocrinology Center, North Hills Health Center, Menomonee Falls, WI 53051, USA
| | | | | | - Anna Oliveras
- Nephrology Department, Hypertension Unit, Hospital del Mar Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Bo-Ching Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin Cent Wu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Zuzana Kratka
- 3rd Department of Medicine, Charles University Prague, General Hospital, Prague, Czech Republic
| | - Teresa M Seccia
- Department of Medicine-DIMED, Emergency and Hypertension Unit, University of Padova, University Hospital, via Giustiniani, 2, 35126 Padova, Italy
| | - Livia Lenzini
- Department of Medicine-DIMED, Emergency and Hypertension Unit, University of Padova, University Hospital, via Giustiniani, 2, 35126 Padova, Italy
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23
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Tezuka Y, Yamazaki Y, Nakamura Y, Sasano H, Satoh F. Recent Development toward the Next Clinical Practice of Primary Aldosteronism: A Literature Review. Biomedicines 2021; 9:biomedicines9030310. [PMID: 33802814 PMCID: PMC8002562 DOI: 10.3390/biomedicines9030310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Revised: 03/08/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022] Open
Abstract
For the last seven decades, primary aldosteronism (PA) has been gradually recognized as a leading cause of secondary hypertension harboring increased risks of cardiovascular incidents compared to essential hypertension. Clinically, PA consists of two major subtypes, surgically curable and uncurable phenotypes, determined as unilateral or bilateral PA by adrenal venous sampling. In order to further optimize the treatment, surgery or medications, diagnostic procedures from screening to subtype differentiation is indispensable, while in the general clinical practice, the work-up rate is extremely low even in the patients with refractory hypertension because of the time-consuming and labor-intensive nature of the procedures. Therefore, a novel tool to simplify the diagnostic flow has been recently in enormous demand. In this review, we focus on recent progress in the following clinically important topics of PA: prevalence of PA and its subtypes, newly revealed histopathological classification of aldosterone-producing lesions, novel diagnostic biomarkers and prediction scores. More effective strategy to diagnose PA based on better understanding of its epidemiology and pathology should lead to early detection of PA and could decrease the cardiovascular and renal complications of the patients.
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Affiliation(s)
- Yuta Tezuka
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
| | - Yuto Yamazaki
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Sendai 981-8558, Japan;
| | - Hironobu Sasano
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan; (Y.Y.); (H.S.)
| | - Fumitoshi Satoh
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan;
- Division of Clinical Hypertension, Endocrinology and Metabolism, Tohoku University Graduate School of Medicine, Sendai 980-8575, Japan
- Correspondence:
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24
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Alnazer RM, Veldhuizen GP, Kroon AA, de Leeuw PW. The effect of medication on the aldosterone-to-renin ratio. A critical review of the literature. J Clin Hypertens (Greenwich) 2021; 23:208-214. [PMID: 33460525 PMCID: PMC8029867 DOI: 10.1111/jch.14173] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 12/22/2020] [Accepted: 12/25/2020] [Indexed: 01/07/2023]
Abstract
The aldosterone-to-renin ratio (ARR) is a common screening test for primary aldosteronism in hypertensives. However, patients often use medications that could confound the ARR and, thereby, reduce the interpretability of the test. Since it is not always feasible to stop such medication, several drugs that are supposedly neutral with respect to the ARR have been recommended as alternative treatment. The objective of the present review is to explore whether sufficient evidence exists to justify the recommendations. To this end, we performed a systematic PubMed and Cochrane literature search regarding medications that may influence the ARR. Our review revealed that many commonly prescribed antihypertensives seem to have significant effects on renin, aldosterone, and resulting ARR values. However, the magnitude of these effects is poorly quantifiable with the present level of research. We conclude that several medications can affect the ARR. Not taking this into account could lead to misinterpretation of the ARR. Therefore, standardization of the medications used during ARR measurement is advisable for a reliable and accurate interpretation. Further research is needed to ascertain how to best optimize these medications.
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Affiliation(s)
- Rawan M Alnazer
- Department of Internal Medicine, Maastricht University Medical Center+ & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Gregory P Veldhuizen
- Department of Internal Medicine, Maastricht University Medical Center+ & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Abraham A Kroon
- Department of Internal Medicine, Maastricht University Medical Center+ & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Peter W de Leeuw
- Department of Internal Medicine, Maastricht University Medical Center+ & Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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25
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Tezuka Y, Turcu AF. Real-World Effectiveness of Mineralocorticoid Receptor Antagonists in Primary Aldosteronism. Front Endocrinol (Lausanne) 2021; 12:625457. [PMID: 33841329 PMCID: PMC8033169 DOI: 10.3389/fendo.2021.625457] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 02/23/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate how often target renin is pursued and achieved in patients with primary aldosteronism (PA) and other low renin hypertension (LRH) treated with mineralocorticoid receptor antagonists (MRAs), as reversal of renin suppression was shown to circumvent the enhanced cardiovascular and renal morbidity and mortality in these patients. PATIENTS AND METHODS We conducted a retrospective cohort study of patients with PA and LRH treated with MRAs in an academic outpatient practice from January 1, 2000, through May 31, 2020. RESULTS Of 30,777 patients with hypertension treated with MRAs, only 7.3% were evaluated for PA. 163 patients (123 with PA) had renin followed after MRA initiation. After a median follow-up of 124 [interquartile range, 65-335] days, 70 patients (43%) no longer had renin suppression at the last visit. The proportion of those who achieved target renin was higher in LRH than in PA (53% vs. 40%). Lower baseline serum potassium, lower MRA doses, and beta-blocker use were independently associated with lower odds of achieving target renin in PA, while male sex was associated with target renin in LRH. Overall, 50 patients (30.7%) had 55 adverse events, all from spironolactone, and 26 patients (52%) were switched to eplerenone or had a spironolactone dose reduction. CONCLUSION Despite evidence that reversal of renin suppression confers cardio-renal protection in patients with PA and LRH, renin targets are followed in very few and are achieved in under half of such patients seen in an academic setting, with possibly even lower rates in community practices.
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Affiliation(s)
- Yuta Tezuka
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, United States
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Adina F. Turcu
- Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, MI, United States
- *Correspondence: Adina F. Turcu,
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26
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Rossi GP, Bisogni V, Rossitto G, Maiolino G, Cesari M, Zhu R, Seccia TM. Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension. High Blood Press Cardiovasc Prev 2020; 27:547-560. [PMID: 33159664 PMCID: PMC7661394 DOI: 10.1007/s40292-020-00415-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/10/2020] [Indexed: 12/14/2022] Open
Abstract
The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i.e. for a 'secondary' form of arterial hypertension. This under detection explains why only a tiny percentage of hypertensive patients are ultimately diagnosed with a secondary form of arterial hypertension. The prevalence of these forms is, therefore, markedly underestimated, although, they can involve as many as one-third of the cases among referred patients and up to half of those with difficult to treat hypertension. The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. Enormous progress has been made in the understanding, diagnostic work-up, and management of secondary hypertension in the last decades. The aim of this minireview is, therefore, to provide updated concise information on the screening, diagnosis, and management of the most common forms, including primary aldosteronism, renovascular hypertension, pheochromocytoma and paraganglioma, Cushing's syndrome, and obstructive sleep apnea.
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Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy.
| | - Valeria Bisogni
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
| | - Giacomo Rossitto
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
| | - Giuseppe Maiolino
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
| | - Rui Zhu
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
| | - Teresa Maria Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine-DIMED, University of Padua, University Hospital, via Giustiniani, 2, 35126, Padova, Italy
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27
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Vaidya A, Carey RM. Evolution of the Primary Aldosteronism Syndrome: Updating the Approach. J Clin Endocrinol Metab 2020; 105:5899581. [PMID: 32865201 PMCID: PMC7899564 DOI: 10.1210/clinem/dgaa606] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/26/2020] [Indexed: 12/19/2022]
Abstract
CONTEXT New approaches are needed to address the evolution of the primary aldosteronism syndrome and to increase its recognition. Herein, we review evidence indicating that primary aldosteronism is a prevalent syndrome that is mostly unrecognized, and present a pragmatic and pathophysiology-based approach to improve diagnosis and treatment. METHODS Evidence was gathered from published guidelines and studies identified from PubMed by searching for primary aldosteronism, aldosterone, renin, and hypertension. This evidence was supplemented by the authors' personal knowledge, research experience, and clinical encounters in primary aldosteronism. INTERPRETATION OF EVIDENCE Renin-independent aldosterone production is a prevalent phenotype that is diagnosed as primary aldosteronism when severe in magnitude, but is largely unrecognized when milder in severity. Renin-independent aldosterone production can be detected in normotensive and hypertensive individuals, and the magnitude of this biochemical phenotype parallels the magnitude of blood pressure elevation, the risk for incident hypertension and cardiovascular disease, and the likelihood and magnitude of blood pressure reduction with mineralocorticoid receptor antagonist therapy. Expansion of the indications to screen for primary aldosteronism, combined with the use of a pathophysiology-based approach that emphasizes inappropriate aldosterone production in the context of renin suppression, will substantially increase the diagnostic and therapeutic yields for primary aldosteronism. CONCLUSIONS The landscape of primary aldosteronism has evolved to recognize that it is a prevalent syndrome of renin-independent aldosterone production that contributes to the pathogenesis of hypertension and cardiovascular disease. Expanding screening indications and simplifying the diagnostic approach will enable implementation of targeted treatment for primary aldosteronism.
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Affiliation(s)
- Anand Vaidya
- Center for Adrenal Disorders, Division of Endocrinology, Diabetes, & Hypertension, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Correspondence and Reprint Requests: Anand Vaidya, MD, MMSc, Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, RFB, Boston, MA 02115, USA. E-mail:
| | - Robert M Carey
- Division of Endocrinology and Metabolism, University of Virginia Health System, Charlottesville, Virginia
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28
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Tezuka Y, Turcu AF. Mineralocorticoid Receptor Antagonists Decrease the Rates of Positive Screening for Primary Aldosteronism. Endocr Pract 2020; 26:1416-1424. [PMID: 33471733 PMCID: PMC7881525 DOI: 10.4158/ep-2020-0277] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 06/16/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Mineralocorticoid receptor antagonists (MRAs) are effective in patients with resistant hypertension and/or primary aldosteronism (PA). Screening for PA should ideally be conducted after stopping medications that might interfere with the renin-angiotensin-aldosterone system, but this is challenging in patients with recalcitrant hypertension or hypokalemia. Herein, we aimed to evaluate the impact of MRAs on PA screening in clinical practice. METHODS We conducted a retrospective cohort study of patients with hypertension who had plasma aldosterone and renin measurements before and after MRA use in a tertiary referral center, over 19 years. RESULTS A total of 146 patients, 91 with PA, were included and followed for up to 18 months. Overall, both plasma renin and aldosterone increased after MRA initiation (from median, interquartile range: 0.5 [0.1, 0.8] to 1.2 [0.6, 4.8] ng/mL/hour and from 19.1 [12.9, 27.7] to 26.4 [17.1, 42.3] ng/dL, respectively; P<.0001 for both), while the aldosterone/renin ratio (ARR) decreased from 40.3 (18.5, 102.7) to 23.1 (8.6, 58.7) ng/dL per ng/mL/hour (P<.0001). Similar changes occurred irrespective of the MRA treatment duration and other antihypertensives used. Positive PA screening abrogation after MRA initiation was found in 45/94 (48%) patients. Conversely, 17% of patients had positive PA screening only after MRA treatment, mostly due to correction of hypokalemia. An initially positive screening test was more likely altered by high MRA doses and more likely persistent in patients with confirmed PA or taking beta-blockers. CONCLUSION MRAs commonly reduce ARR and the proportion of positive PA screening results. When PA is suspected, screening should be repeated off MRAs. ABBREVIATIONS ACEI = angiotensin-converting enzyme inhibitor; ARB = angiotensin receptor blocker; ARR = aldosterone/renin ratio; DRC = direct renin concentration; MRA = mineralocorticoid receptor antagonist; PA = primary aldosteronism; PAC = plasma aldosterone concentration; PRA = plasma renin activity; RAAS = renin-angiotensin-aldosterone system.
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Affiliation(s)
- Yuta Tezuka
- From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and; Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Adina F Turcu
- From the (1)Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, and.
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29
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Resolution of drug-resistant hypertension by adrenal vein sampling-guided adrenalectomy: a proof-of-concept study. Clin Sci (Lond) 2020; 134:1265-1278. [DOI: 10.1042/cs20200340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 05/07/2020] [Accepted: 05/26/2020] [Indexed: 11/17/2022]
Abstract
Abstract
Drug-resistant hypertension (RH) is a very high-risk condition involving many hypertensive patients, in whom primary aldosteronism (PA) is commonly overlooked. Hence, we aimed at determining if (1) adrenal vein sampling (AVS) can identify PA in RH patients, who are challenging because of receiving multiple interfering drugs; (2) AVS-guided adrenalectomy can resolve high blood pressure (BP) resistance to treatment in these patients.
Based on a pilot study we selected from 1016 consecutive patients referred to our Centre for ‘difficult-to-treat’ hypertension those with RH, for an observational prospective cohort study. We excluded those non-adherent to treatment (by therapeutic drug monitoring) and those with pseudo-RH (by 24-h BP monitoring), which left 110 patients who met the European Society of Cardiology/European Society of Hypertension (ESC/ESH) 2013 definition for RH. Of these patients, 77 were submitted to AVS, who showed unilateral PA in 27 (mean age 55 years; male/female 19/8). Therefore, these patients underwent AVS-guided laparoscopic unilateral adrenalectomy, which resolved RH in all: 20% were clinically cured in that they no longer needed any antihypertensive treatment; 96% were biochemically cured. Systolic and diastolic BP fell from 165/100 ± 26/14 mmHg at baseline, to 132/84 ± 14/9 mmHg at 6 months after surgery (P<10−4 for both) notwithstanding the fall of number and defined daily dose (DDD) of antihypertensive drugs required to achieve BP control (P<10−4 for both). A prominent regression of cardiac and renal damage was also observed.
Thus, the present study shows the feasibility of identifying PA by AVS in RH patients, and of resolving high BP resistance to treatment in these patients by AVS-guided adrenalectomy.
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30
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Rossi GP, Bisogni V, Bacca AV, Belfiore A, Cesari M, Concistrè A, Del Pinto R, Fabris B, Fallo F, Fava C, Ferri C, Giacchetti G, Grassi G, Letizia C, Maccario M, Mallamaci F, Maiolino G, Manfellotto D, Minuz P, Monticone S, Morganti A, Muiesan ML, Mulatero P, Negro A, Parati G, Pengo MF, Petramala L, Pizzolo F, Rizzoni D, Rossitto G, Veglio F, Seccia TM. The 2020 Italian Society of Arterial Hypertension (SIIA) practical guidelines for the management of primary aldosteronism. INTERNATIONAL JOURNAL CARDIOLOGY HYPERTENSION 2020; 5:100029. [PMID: 33447758 PMCID: PMC7803025 DOI: 10.1016/j.ijchy.2020.100029] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
Background and aim Considering the amount of novel knowledge generated in the last five years, a team of experienced hypertensionlogists was assembled to furnish updated clinical practice guidelines for the management of primary aldosteronism. Methods To identify the most relevant studies, the authors utilized a systematic literature review in international databases by applying the PICO strategy, and then they were required to make use of only those meeting predefined quality criteria. For studies of diagnostic tests, only those that fulfilled the Standards for Reporting of Diagnostic Accuracy recommendations were considered. Results Each section was jointly prepared by at least two co-authors, who provided Class of Recommendation and Level of Evidence following the American Heart Association methodology. The guidelines were sponsored by the Italian Society of Arterial Hypertension and underwent two rounds of revision, eventually reexamined by an External Committee. They were presented and thoroughly discussed in two face-to-face meetings with all co-authors and then presented on occasion of the 36th Italian Society of Arterial Hypertension meeting in order to gather further feedbacks by all members. The text amended according to these feedbacks was subjected to a further peer review. Conclusions After this process, substantial updated information was generated, which could simplify the diagnosis of primary aldosteronism and assist practicing physicians in optimizing treatment and follow-up of patients with one of the most common curable causes of arterial hypertension.
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Affiliation(s)
- Gian Paolo Rossi
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- Corresponding author. DIMED –Clinica dell’Ipertensione Arteriosa, University Hospital, via Giustiniani, 2; 35126, Padova, Italy.
| | - Valeria Bisogni
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | | | - Anna Belfiore
- Clinica Medica "A. Murri", Department of Biomedical Sciences and Human Oncology, University of Bari Medical School, Bari, Italy
| | - Maurizio Cesari
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Antonio Concistrè
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Rita Del Pinto
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | - Bruno Fabris
- Department of Medical Sciences, Università degli Studi di Trieste, Cattinara Teaching Hospital, Trieste, Italy
| | - Francesco Fallo
- Department of Medicine, DIMED, Internal Medicine 3, University of Padua, Italy
| | - Cristiano Fava
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Claudio Ferri
- University of L'Aquila, Department of Life, Health and Environmental Sciences, San Salvatore Hospital, L'Aquila, Italy
| | | | | | - Claudio Letizia
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Mauro Maccario
- Endocrinology, Diabetology, and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Francesca Mallamaci
- CNR-IFC Clinical Epidemiology of Renal Diseases and Hypertension, Reggio Calabria, Italy
| | - Giuseppe Maiolino
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
| | - Dario Manfellotto
- UO Medicina Interna, Ospedale Fatebenefratelli Isola Tiberina, Rome, Italy
| | - Pietro Minuz
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Silvia Monticone
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Alberto Morganti
- Centro Fisiologia Clinica e Ipertensione, Ospedale Policlinico, Università Milano, Milan, Italy
| | - Maria Lorenza Muiesan
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Paolo Mulatero
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Aurelio Negro
- Department of Medicine, Center for Hypertension, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Gianfranco Parati
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Martino F. Pengo
- Department of Medicine and Surgery, University of Milano-Bicocca and Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Luigi Petramala
- Department of Translational and Precision Medicine, Unit of Secondary Arterial Hypertension, "Sapienza" University of Rome, Italy
| | - Francesca Pizzolo
- Department of Medicine, University of Verona, Policlinico "G.B. Rossi", Italy
| | - Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Italy
| | - Giacomo Rossitto
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
- University of Glasgow, Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Franco Veglio
- Hypertension Unit, Division of Internal Medicine, Department of Medical Sciences, University of Turin, Italy
| | - Teresa Maria Seccia
- Clinica dell'Ipertensione Arteriosa, Department of Medicine - DIMED, University of Padua, Italy
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