What is the cause of episodic hypertension with dizziness and cognitive impairment in a patient with primary aldosteronism (Hyperaldosteronism)?

From the Guidelines

For blood pressure spikes with dizziness and brain fog in a patient with primary aldosteronism, immediate medical attention is needed, and treatment typically includes aldosterone antagonists like spironolactone or eplerenone, with possible addition of blood pressure medications and surgical removal of an adrenal adenoma if a unilateral source is identified. The symptoms experienced by the patient, such as dizziness and brain fog, are due to excess aldosterone causing sodium and water retention, increasing blood volume and blood pressure, while potassium loss affects nerve and muscle function 1.

Treatment Approach

• Aldosterone antagonists like spironolactone (starting at 25-50mg daily, gradually increasing to 100-400mg daily as needed) or eplerenone (50-100mg daily) are recommended to block aldosterone receptors, reducing sodium retention and potassium loss 2.
• Blood pressure medications such as calcium channel blockers (amlodipine 5-10mg daily) or ACE inhibitors may be added if needed to control blood pressure.
• Surgical removal of an adrenal adenoma (adrenalectomy) is recommended if imaging identifies a unilateral source, as it can improve blood pressure in virtually 100% of patients and result in a complete cure of hypertension in about 50% of cases 3.

Management Considerations

• Maintain a low-sodium diet (less than 2,300mg daily) to reduce sodium retention and blood volume.
• Stay well-hydrated to prevent dehydration and electrolyte imbalances.
• Monitor potassium levels regularly to prevent hypokalemia and its complications.
• Regular monitoring of blood pressure, electrolytes, and kidney function is essential during treatment to adjust medications and prevent complications 4, 5.

Diagnosis and Screening

• The aldosterone:renin activity ratio is currently the most accurate and reliable means of screening for primary aldosteronism, with a cutoff value of 30 when plasma aldosterone concentration is reported in nanograms per deciliter (ng/dL) and plasma renin activity in nanograms per milliliter per hour (ng/mL/h) 1.
• Patients with hypertension and a history of early onset hypertension and/or cerebrovascular accident at a young age may have primary aldosteronism due to glucocorticoid-remediable aldosteronism (familial hyperaldosteronism type-1) and therefore warrant screening 2.

From the FDA Drug Label

Spironolactone and its active metabolites are specific pharmacologic antagonists of aldosterone, acting primarily through competitive binding of receptors at the aldosterone-dependent sodium-potassium exchange site in the distal convoluted renal tubule. Increased levels of the mineralocorticoid, aldosterone, are present in primary and secondary hyperaldosteronism. Spironolactone counteracts secondary aldosteronism induced by the volume depletion and associated sodium loss caused by active diuretic therapy. Spironolactone tablets are indicated for the management of edema in the following settings: Spironolactone tablets are indicated in the following settings: Short-term preoperative treatment of patients with primary hyperaldosteronism.

Blood Pressure Spikes with Dizziness and Brain Fog in Primary Aldosteronism

• The patient's symptoms of blood pressure spikes with dizziness and brain fog may be related to the underlying primary aldosteronism.
• Spironolactone, an aldosterone antagonist, is indicated for the treatment of primary hyperaldosteronism and may help alleviate these symptoms by counteracting the effects of excess aldosterone.
• However, the exact relationship between spironolactone and the patient's symptoms is not explicitly stated in the drug label.
• Key Considerations: + Primary aldosteronism is characterized by excess aldosterone production, which can lead to hypertension and other symptoms. + Spironolactone is an effective treatment for primary hyperaldosteronism, but its effects on blood pressure spikes, dizziness, and brain fog are not directly addressed in the label. + Patients with primary aldosteronism may require individualized treatment and monitoring to manage their symptoms and prevent complications 6, 7.

From the Research

Blood Pressure Spikes and Primary Aldosteronism

• Blood pressure spikes with dizziness and brain fog in patients with primary aldosteronism can be managed with mineralocorticoid receptor antagonists, which have been shown to significantly improve blood pressure and serum potassium levels 8, 9, 10.
• The use of mineralocorticoid receptor antagonists, such as spironolactone and eplerenone, is recommended as the first-line treatment for patients with bilateral primary aldosteronism 8, 9.
• For patients with unilateral aldosterone-producing adenoma, adrenalectomy is the preferred treatment option 8, 11.
• Mineralocorticoid receptor antagonists have been shown to reverse left ventricular hypertrophy, albuminuria, and carotid intima-media thickness in patients with primary aldosteronism 8.
• However, a high risk for atrial fibrillation remains among subjects with primary aldosteronism treated with mineralocorticoid receptor antagonists 8.

Treatment Options

• Spironolactone has been the drug of choice to treat primary aldosteronism, but it is not selective for the aldosterone receptor and has side effects such as gynecomastia, erectile dysfunction, and menstrual irregularity 9.
• Eplerenone is a new competitive and selective aldosterone receptor antagonist that lacks the side effects associated with spironolactone and may be a superior treatment option 9, 10.
• New aldosterone blockers are being developed to overcome the limitations of classic mineralocorticoid receptor antagonists, including nonsteroidal MRAs and inhibition of aldosterone synthesis 12.

Management of Primary Aldosteronism

• Clinicians should perform case detection testing for primary aldosteronism at least once in all patients with hypertension 11.
• Confirmatory testing is indicated in most patients with positive case detection testing results, and the next step is to determine whether patients with confirmed primary aldosteronism have a disease that can be cured with surgery or whether it should be treated medically 11.
• A low-sodium diet and lifelong treatment with a mineralocorticoid receptor antagonist are recommended for patients with bilateral aldosterone hypersecretion 11.