Publications

The Primary Aldosteronism Foundation maintains a list of salient publications. Topics range from pathogenesis to the implications of excess aldosterone. We regularly update the list with new topics, and new articles are added as they become public.

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Abstract/Summary

Hypertension is common, costly, and controllable. Almost 1 in 2 US adults has hypertension, and among those, the estimated rate of controlled blood pressure was only 43.7% in 2017-2018 a decline from 53.8% in 2013-2014. Uncontrolled blood pressure can lead to largely preventable events such as myocardial infarction, stroke, and maternal mortality, as well as debilitating and expensive conditions such as kidney disease, heart failure, and cognitive decline. Hypertensive disorders of pregnancy, which have increased in the US, contribute to adverse maternal and child health outcomes and can increase a woman’s lifetime risk of cardiovascular disease. Disparities in blood pressure control and, consequently, in these health outcomes, persist by race and ethnicity, age, and geography. Yet broad and equitable hypertension control is possible, and some health care practices and systems have achieved rates of 80% or higher across a wide spectrum of sites and populations served.

Authors: Jerome M. Adams, Janet S. Wright
Keywords: blood pressure, hypertension, measurement, control, prevalence
DOI Number: 10.1001/jama.2020.20356
Publication Year: 2020

Abstract/Summary

Has blood pressure control changed among adults with hypertension over the past 20 years in the US? In this serial cross-sectional study that included 18 262 US adults aged 18 years or older with hypertension, with data weighted to be representative of the US population, the age-adjusted estimated proportion with controlled blood pressure increased from 31.8% in 1999-2000 to 48.5% in 2007-2008, remained stable through 2013-2014 (53.8%), and then declined to 43.7% in 2017-2018.

Authors: Paul Muntner, Shakia T. Hardy, Lawrence J. Fine, Byron C. Jaeger, Gregory Wozniak, Emily B. Levitan, Lisandro D. Colantonio
Keywords: blood pressure, hypertension, measurement, control, prevalence
DOI Number: 10.1001/jama.2020.14545
Publication Year: 2020

Abstract/Summary

Primary aldosteronism (PA) is the most common form of secondary hypertension. In many cases, somatic mutations in ion channels and pumps within adrenal cells initiate the pathogenesis of PA, and this mechanism might explain why PA is so common and suggests that milder and evolving forms of PA must exist. Compared with primary hypertension, PA causes more end-organ damage and is associated with excess cardiovascular morbidity, including heart failure, stroke, nonfatal myocardial infarction, and atrial fibrillation. Screening is simple and readily available, and targeted therapy improves blood pressure control and mitigates cardiovascular morbidity. Despite these imperatives, screening rates for PA are low, and mineralocorticoid-receptor antagonists are underused for hypertension treatment. After the evidence for the prevalence of PA and its associated cardiovascular morbidity is summarized, a practical approach to PA screening, referral, and management is described. All physicians who treat hypertension should routinely screen appropriate patients for PA.

Authors: James Brian Byrd, Adina F. Turcu, Richard J. Auchus
Keywords: aldosterone, pathogenesis, diagnosis, screening, confirmatory testing, subtyping, medical therapy
DOI Number: 10.1161/CIRCULATIONAHA.118.033597
Publication Year: 2018

Abstract/Summary

Several studies over the past 3 decades document a higher prevalence of primary aldosteronism (PA) among hypertensive patients than generally presumed. PA exists as a spectrum from mild to severe aldosterone excess. Although a variety of PA subtypes exist, the two most common are aldosterone-producing adenomas (APAs) and bilateral hyperaldosteronism (BHA). The distinction is important, because APA – and other subtypes with aldosterone production mostly from one adrenal – can be cured surgically, and BHA should be treated medically with mineralocorticoid-receptor antagonists (MRAs). The major shortcomings in the tailored management of patients with possible PA are the low rates of screening for case identification and the expensive and technically challenging imaging and interventional procedures required to distinguish APA from BHA, especially adrenal vein sampling (AVS). When AVS identifies an APA and allows the patient to be cured surgically, the procedure is of great value. In contrast, the patient with BHA is treated with MRA whether AVS is performed or not. Consequently, it is prudent to gauge how likely it is to benefit from imaging and AVS in each case prior to embarking on these studies. The explosion of information about PA in the last decade, including predictors of APA and of surgical benefit, are useful in limiting the evaluation for some patients with a positive PA screening test. This article will review our suggestions for approaching these patients in a pragmatic style, recognizing the limitations to even the best resources and facilities.

Authors: Adina F Turcu, Richard Auchus
Keywords: primary aldosteronism, adrenal, aldosterone, hypertension, adrenal vein sampling, prevalence
DOI Number: 10.1210/clinem/dgaa952
Publication Year: 2020

Abstract/Summary

This study is the first to examine the daily clinical practice work-up of PA within a worldwide cohort of surgical patients. The results demonstrate significant variability in work-up strategies and low adherence to The Endocrine Society guideline. Patients who underwent unilateral adrenalectomy for PA within 16 centers in Europe, Canada, Australia and the USA between 2010 and 2016 were included. In total, 435 patients were eligible. An aldosterone-to-renin ratio, confirmatory test, computed tomography (CT), magnetic resonance imaging and AVS were performed in 82.9%, 32.9%, 86.9%, 17.0% and 65.3% of patients, respectively. A complete work-up, as recommended by the guideline, was performed in 13.1% of patients. Bilateral disease or normal adrenal anatomy on CT (OR 16.19; CI 3.50-74.99), smaller tumor size on CT (OR 0.06; CI 0.04-0.08) and presence of hypokalemia (OR 2.00; CI 1.19-3.32) were independently associated with performing AVS.

Authors: Wessel M C M Vorselaars, Dirk-Jan van Beek, Diederik P D Suurd, Emily Postma, Wilko Spiering, Inne H M Borel Rinkes, Gerlof D Valk, Menno R Vriens, International CONNsortium
Keywords: adrenalectomy, work-up, clinical practice, guideline, Endocrine Society
DOI Number: 10.1007/s00268-020-05408-2
Publication Year: 2020

Abstract/Summary

Primary aldosteronism is a common cause of treatment-resistant hypertension. However, evidence from local health systems suggests low rates of testing for primary aldosteronism. The objective of this retrospective cohort study was to evaluate testing rates for primary aldosteronism and evidence-based hypertension management. In a nationally distributed cohort of veterans with apparent treatment-resistant hypertension, testing for primary aldosteronism was rare and was associated with higher rates of evidence-based treatment with MRAs and better longitudinal BP control. The findings reinforce prior observations of low adherence to guideline-recommended practices in smaller health systems and underscore the urgent need for improved management of patients with treatment-resistant hypertension.

Authors: Jordana B. Cohen, Debbie L. Cohen, Daniel S. Herman, John T. Leppert
Keywords: screening, diagnosis, testing rate
DOI Number: 10.7326/M20-4873
Publication Year: 2020