Assessment of Cardiovascular Disease Risk by Plasma Renin Activity Changes in Patients With Primary Aldosteronism on Mineralocorticoid Receptor Antagonist Treatment

Primary aldosteronism (PA), the most common cause of endocrine arterial hypertension, is caused by autonomous hypersecretion of aldosterone from the adrenal glands. Plasma renin activity (PRA) is suppressed due to excessive mineralocorticoid receptor (MR) activation and volume expansion. Patients with PA are at a higher risk of cardiovascular and cerebrovascular events, heart and renal diseases, diabetes mellitus, metabolic syndrome, and reduced quality of life than patients with essential hypertension. These risks are independent of blood pressure elevation. Treatment with MR antagonists (MRAs) is recommended for patients with bilateral PA and those with unilateral PA who are unwilling or unable to undergo adrenalectomy. However, studies have shown that some patients with PA treated with MRAs have a higher incidence of cardiovascular disease (CVD) than essential hypertensive controls. An increase in PRA caused by MRA therapy may reflect sufficient antagonism of the MR. Hundemer et al. conducted a large cohort study assessing 602 patients with PA treated with MRAs and 41,853 age-matched patients with essential hypertension; they found that the risk of CVD in patients with PA who achieved unsuppressed renin levels (≥1 ng/ml/h) with MRA treatment was comparable to that in patients with essential hypertension. Thus, titration of MRA aimed at avoiding the suppression of renin activity may help improve CVD outcomes in patients with PA. However, very few large studies have focused on CVD outcomes and risk factors, including renin levels, in patients with PA receiving MRA treatment.