Clinical Characteristics, Prognosis And Cardiovascular Disease Risk Factors Of Primary Aldosteronism

Backgrounds:Primary aldosteronism(PA)and renal artery stenosis(RAS)are common causes of secondary hypertension.In individuals with both diseases,clinical manifestations are more complicate.RAS may lead to missed diagnosis of PA by effecting the result of screening test of PA.By now,there is still a lack of relevant clinical studies on concurrent PA and RAS.Aims:To explore the clinical features of coexisting PA and RAS,and to analyze the effect of the RAS on the screening test of PA.Methods:We retrospectively analyzed records from 71 patients with PA with RAS and a control group of 121 patients with PA without RAS.The former group was further divided into severe RAS(RAS>70%)and moderate RAS(50%<RAS<70%)groups.Results:The prevalence of RAS among patients with PA was 6.9%(71/1033),including 3.2%(33/1033)with severe RAS.Compared with the PA without RAS group,the severe RAS group showed higher levels of systolic blood pressure(171.82±18.24vs.154.11±18.96mmHg;P<0.001),diastolic blood pressure(110.76±15.90vs.91.73±12.85mmHg;P<0.001)and prevalence of resistant hypertension(RH)(90.9%vs.66.9%;P=0.008),whereas the moderate RAS group merely showed higher diastolic blood pressure(98.63±14.90vs.91.73±12.85mmHg;P=0.006).The direct renin concentration(5.37±3.94vs.3.71±2.10 uIU/ml;P<0.001)and false-negative rate(33.8%vs.3.3%;P<0.01)of PA screening tests were significantly higher in the PA with RAS group than in the control group,respectively.However,such differences were presented only in the severe RAS group,but not in the moderate RAS group,in subgroup analysis.Supine direct renin concentration and plasma aldosterone concentration were re-evaluated in 19 of those patients when they were re-admitted for missed diagnosis of PA.Supine direct renin concentration lowered from 11.22±9.10 to 3.24±2.69 ulU/ml(P<0.001)and the prevalence of low-renin status increased from 21.1%(4/19)to 78.9%(15/19)(P=0.001),compared with the baseline levels before revascularization treatment for RAS;however,no significant difference was observed in plasma aldosterone concentration(23.22±11.20vs.22.45±8.90ng/dL;P=0.697).At the latest follow-up,prevalence of RH(2.8%vs.81.7%;P<0.001)were significantly lower than those recorded at baseline when both PA and RAS treated by standard strategies.Conclusions:PA is easy to be missed in patients with coexisting RAS because of false-negative result of screening test of PA,which mainly caused by elevated renin level contributing to severe RAS.Successful revascularization for RAS can effectively reduce the level of plasma renin.RAS patients with unimproved hypertension and/or RH after successful revascularization for RAS should be evaluated for coexisting PA when common causes were carefully excluded.Backgrounds:Primary aldosteronism(PA)is a cardiovascular risk factor independent of hypertension.Proper treatment is crucial to improve the long-term prognosis of PA.Although both surgical treatment and single medication treatment were considered as effective methods in controlling hypertension and reducing the incidence of cardiovascular disease,the comparison of long-term outcomes between surgery versus medicine treatment among patients with unilateral PA diagnosed by adrenal venous sampling(AVS)is uncertain.Aims:To explore clinical value of AVS in subtype classification of PA and effectiveness of surgical versus medical treatment on the long-term blood pressure control and incidence of cardiovascular disease among patients with AVS-proven unilateral PA.Methods:The clinical value of AVS on subtype classification of PA was evaluated by comparing the consistence between AVS and imaging test.Patients with AVS-proven unilateral PA were divided into the surgery-treatment group and medication-treatment group to evaluate the complete control rate of blood pressure,type of hypotensors and incidence of cardiovascular disease after the long-term follow-up.The effect of surgical treatment on long-term blood pressure control was evaluated by Cox proportional hazards models.Results:Totally 51 patients were included in our research.The patients were divided into a surgery-treatment group(21 participants)and a medication-treatment group(30 participants).The overall coincidence rate between AVS and computer tomography(CT)scan results was 64.7%(33/51).The lesion showed by CT was opposite to that determined by AVS in 19.6%(10/51)of all patients,and 15.7%(8/51)of all patients with bilateral adrenal lesions showed on CT scan were found to have dominant secretion by AVS.The mean follow-up period in the surgery group and medication group was 22.05±6.26 and 20.57±4.63 months,respectively(P=0.34).In the surgery group,the systolic blood pressure(BP)(120.30±12.99vs.151.67±14.59mmHg;P<0.001),diastolic BP(79.00±7.62vs.93.81±12.14mmHg;P<0.001),type of hypotensors(0.19±0.51vs.2.19±1.08;P<0.001),and hypokalemia rate(0.0%vs.95.2%;P<0.001)were significantly lower at follow-up than at the first admission.In the medication group,the systolic BP(133.54±16.60vs.156.33±21.34mmHg;P<0.001)and prevalence of hypokalemia(13.3%vs.66.7%;P<0.001)were significantly lower at the latest follow-up.At the latest follow-up,systolic BP(120.30±12.99vs.133.54±16.60vs.133.54±16.60mmHg;P=0.01),diastolic BP(79.00±7.62vs.87.35±12.36mmHg;P=0.01)and type of hypotensors(0.19±0.51vs.2.33±0.78;P<0.001)significantly decrease in the surgery-treatment group than the medication-treatment group;however,the prevalence of hypokalemia showed no difference(0.0%vs.13.3%;P=0.13).The complete control rate of surgery-treatment group was higher than the medication-treatment group(85.7%vs.13.3%;P<0.001).Before adjustment for multiple relevant covariates in the Cox proportional hazards model,the complete control rate of high blood pressure among those having underwent surgical treatment was as high as 7.75 times than that among patients having received medical treatment(95%confidence interval[2.33,25.78];P=0.001).The adjusted models also drew the similar results.There was no significant difference in the incidence of cardiovascular events between the two groups.Conclusions:Conducting AVS to clarify the subtype classification of PA before surgical treatment can effectively prevent patients from receiving unreasonable surgical treatment.Both surgical and medical treatment can effectively control blood pressure and hypokalemia among patients with unilateral PA diagnosed by AVS,but the long-term blood pressure control was better among patients treated by surgeries than those treated merely by drugs.Surgical treatment may be an independent protective factor to improve the long-term blood pressure control among PA patients.Backgrounds:Primary aldosteronism(PA)can lead to an increased risk of cardiovascular disease(CVD).However,there are few studies focusing on the risk factors of CVD in PA patients among Chinese population,especially on the relationship between CVD risk and parameters acquired in ambulatory blood pressure monitoring(ABPM)and branchial-ankle pulse wave velocity(baPWV).By identifying and controlling the risk factors of CVD,it is helpful to reduce the risk of cardiovascular disease in patients with PA and improve the long-term prognosis.Aims:To analyze the clinical characteristics,ABPM results and baPWV in PA patients,and to further explore the potential risk factors of CVD in those patients.Methods:The data of PA patients diagnosed from 2016 to 2017 were retrospectively collected.The participants were divided into CVD group and non-CVD group according to whether the patients were concurrent with CVDs at admission.The baseline data,ABMP results and baPWV results of the two groups were compared.The potential risk factors leading to the increased risk of CVD in PA patients were explored by bivariate correlation analysis,and all potential risk factors were further analyzed by multivariate logistic regression(MLR)analysis.Results:Compared with non-CVD group,the age at diagnosis(57.77±8.23vs.45.81±10.66 years;P<0.001),the course of hypertension(17.77±11.57vs.9.90±8.48 years;P<0.01);pulse pressure(64.84±14.17vs.56.48±12.61mmHg;P<0.001),low density lipoprotein cholesterol level(LDLC)(3.07±0.86vs.2.69±0.72 mmol/L;P=0.002)and glycosylated hemoglobin level(5.80±0.76vs.5.51±0.57%;P=0.004)were significantly higher in the CVD group,while high density lipoprotein cholesterol level(11.06±0.24vs.1.19±0.33 mmol/L;P=0.010)was significantly lower in the CVD group.Based on ABPM,the normal blood pressure rhythm was only found in 13.6%of PA patients.There were 81.5%of PA patients showed non-dipper blood,and 33.2%of them had higher nocturnal blood pressure than daytime blood pressure.However,there was no significant difference in blood pressure rhythm between CVD group and non-CVD group.According to data of baPWV,81.5%of PA patients were diagnosed with arteriosclerosis,and the absolute level of baPWV(17.28±3.29vs.15.86±2.64 m/s;P=0.002)and the prevalence of arteriosclerosis(94.6%vs.75.8%;P=0.002)were higher in the CVD group higher than those in the non-CVD group.MLR analysis showed that elderly patients at diagnosis(OR 1.122,95%confidence interval[1.071,1.176];P<0.001),increased pulse pressure(OR 1.036,95%confidence interval[1.003,1.071];P=0.033),elevated LDLC(OR 1.786,95%confidence interval[1.019,3.129];P=0.043),elevated serum creatinine(OR 1.025,95%confidence interval[1.005,1.044];P=0.012)and elevated renin levels(OR 1.010,95%confidence interval[1.001,1.018];P=0.024)were risk factors for CVD among PA patients.Conclusions:The majority of PA patients have abnormal blood pressure rhythm,which mainly manifested as "non-dipper" blood pressure,and most of PA patients had elevated baPWV and arteriosclerosis.Advanced age at diagnosis,increased pulse pressure,and elevated level of LDLC,serum creatinine and renin in plasma may be used as clinical markers for predicting the CVD risks.