From the Guidelines
Hyperaldosteronism is characterized by excessive aldosterone production, leading to hypertension, hypokalemia, metabolic alkalosis, and muscle weakness, with the most recent guidelines recommending screening for primary aldosteronism in patients with hypertension at increased risk, using the aldosterone:renin activity ratio as the most accurate and reliable means of screening 1. The clinical features of hyperaldosteronism include:
- Hypertension that is often resistant to standard treatments
- Hypokalemia (low potassium levels)
- Metabolic alkalosis
- Muscle weakness or cramping
- Fatigue, headaches, polyuria (increased urination), polydipsia (increased thirst), and paresthesias (abnormal sensations like tingling) Notably, many patients with primary hyperaldosteronism may have normal potassium levels, making hypertension the only presenting sign in up to 50% of cases. The condition can lead to cardiovascular complications including left ventricular hypertrophy, atrial fibrillation, and increased risk of stroke or heart attack if left untreated. The underlying mechanism involves excess aldosterone causing increased sodium reabsorption and potassium excretion in the distal tubules of the kidneys, leading to volume expansion and hypertension, typically resulting in suppressed plasma renin activity 2, 3, 4, 5, 6. Early recognition of these features is crucial as specific treatments like mineralocorticoid receptor antagonists (spironolactone or eplerenone) or surgical intervention for aldosterone-producing adenomas can effectively manage the condition and prevent long-term complications, with the most recent guidelines recommending the use of newer agents such as finerenone and exarenone, and the aldosterone synthase inhibitor baxdrostat, which lower BP in resistant hypertension, and are being tested for treating primary aldosteronism 1.
From the Research
Clinical Features of Hyperaldosteronism
The clinical features of hyperaldosteronism are primarily related to the excessive production of aldosterone, which can lead to various symptoms and complications. Some of the key clinical features include:
- Hypertension: Hyperaldosteronism is a common cause of secondary hypertension, which can increase the risk of cardiovascular disease and other complications 7, 8, 9, 10, 11.
- Hypokalemia: Excessive aldosterone production can lead to potassium loss, resulting in hypokalemia, which can cause muscle weakness, fatigue, and other symptoms 9, 11.
- Metabolic alkalosis: Hyperaldosteronism can also lead to metabolic alkalosis, which can cause symptoms such as nausea, vomiting, and confusion 9.
- Cardiovascular disease: Hyperaldosteronism has been linked to an increased risk of cardiovascular disease, including heart failure, stroke, and kidney disease 7, 8, 10.
Diagnosis and Treatment
The diagnosis of hyperaldosteronism typically involves a combination of clinical evaluation, laboratory tests, and imaging studies. Some of the key diagnostic tests include:
- Plasma aldosterone-to-renin ratio (ARR): This test is used to screen for hyperaldosteronism and can help identify patients who require further evaluation 8, 9, 10, 11.
- Confirmatory tests: These tests, such as oral sodium loading or saline infusion, can help confirm the diagnosis of hyperaldosteronism 9, 10.
- Imaging studies: Computed tomography (CT) or magnetic resonance imaging (MRI) scans can help identify adrenal tumors or other abnormalities that may be causing hyperaldosteronism 9, 10.
- Adrenal venous sampling: This test can help determine whether the excess aldosterone production is coming from one or both adrenal glands 8, 10.
Treatment for hyperaldosteronism depends on the underlying cause and may include:
- Surgery: For patients with unilateral adrenal tumors, surgical removal of the affected gland can be curative 8, 10, 11.
- Medications: Mineralocorticoid receptor antagonists, such as spironolactone, can help control blood pressure and reduce aldosterone production in patients with bilateral hyperaldosteronism 8, 10, 11.