In majority of patients, hypertension is found to be primary (essential or idiopathic) meaning they have no specific cause. A subgroup of patients may have secondary cause of hypertension. In young patients (less than 40 years old), prevalence of secondary hypertension is high and estimated to be around 30%. Primary aldosteronism (PA) is a common cause of hypertension. Generally accepted prevalence of Primary Aldosteronism is about 10% of patients with hypertension, although there is compelling evidence that even this might be a major underestimate.
Primary Aldosteronism (PA) arises when the adrenal glands, located above the kidneys, produce too much aldosterone hormone. This disrupts sodium and potassium levels in the blood, leading to high blood pressure and other symptoms like muscle cramps and weakness. Sometimes, such patients are asymptomatic and their presentation may be indistinguishable from essential hypertension. Hypertension may be resistant to treatment and may be accompanied by low potassium levels in blood. The individuals who have PA face significantly higher risks of stroke, myocardial infarction (heart attack), atrial fibrillation (irregular heart rhythm) and kidney damage compared to those with essential hypertension. Making a correct underlying diagnosis is of utmost importance for such patients. The standard blood pressure medications often fall short for them, and specific treatments like Mineralocorticoid Receptor (MR) antagonists offer much better results for PA patients. However, PA is often undiagnosed due to low awareness among healthcare providers. Recognizing that PA is more common and serious than once thought is vital. There are 2 common subtypes of PA: Aldosterone-producing adenoma (APA) and Bilateral idiopathic hyperaldosteronism (IHA). After the screening and confirmatory test, the next step is to determine whether patients with PA have a disease that can be cured with surgery (unilateral disease)or whether it should be treated medically (bilateral disease); this step is guided by Computed Tomography (CT) scan of the adrenal glands followed by Adrenal Venous Sampling (AVS) if required. The AVS is the gold standard test to distinguish unilateral from bilateral disease in patients with PA. Early detection offers the chance for effective treatment, which can prevent severe heart and kidney damage.
At Canadian Specialist Hospital (CSH), Dubai, a young lady with hypertension and severely low potassium was managed in a successful way. She underwent unilateral adrenalectomy for adrenal adenoma and she got cured of her high blood pressure and the problem of low potassium is also completely resolved. There was another patient who underwent AVS to distinguish between subtypes of PA. AVS is a technically difficult procedure which is available at few centres in the country. This procedure was done successfully at CSH. He was started on targeted therapy and his problem of PA was diagnosed and managed effectively. Anyone experiencing symptoms suggestive of PA should seek advice from an endocrinologist and undergo a simple blood test to measure aldosterone and renin levels. Table 1 gives a list of high-risk groups in whom screening for PA is of paramount importance. Previously it was thought that screening is very complicated requiring stopping of all medications except few. Over time, it has been shown that that case detection testing can be completed without stopping antihypertensive medications. Treatment depends on the underlying cause. If both adrenal glands are overactive, specific medication can manage this condition while if only one gland is overactive due to adrenal adenoma, that gland is removed with minimally invasive surgery, and there is even a chance of complete cure depending upon the duration of hypertension and other factors. Early diagnosis is crucial for managing Primary Aldosteronism effectively. Increasing awareness among healthcare professionals and promoting screening for PA are crucial steps in addressing this threat to public health. Primary Aldosteronism despite being a common form of secondary hypertension is often underdiagnosed and only the tip of the iceberg is being screened!
Table 1 Recommendation to screen for primary aldosteronism: High-risk individuals (meeting any of these criteria) –
1.People with resistant hypertension on 3 conventional antihypertensive medications.
2.People whose hypertension is controlled with 4 or more antihypertensive medications.
3.People with hypertension and low potassium in the blood.
4.Those who have hypertension and a mass on the adrenal gland (adrenal incidentaloma).
5.People with hypertension and obstructive sleep apnea.
6.People with hypertension and a family history of early-onset hypertension or stroke before age 40.
7.All hypertensive first-degree relatives of patients with primary aldosteronism.
8.Onset of hypertension at a young age (before age 40).
9.Severe hypertension (≥160 mm Hg systolic or ≥100 mm Hg diastolic).
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