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Adrenalectomy in unilateral primary aldosteronism: benefits for most patients even those with persistent hypertension

By Rebecca Jenkins
Adrenalectomy cures or improves hypertension in most patients with unilateral primary aldo­steronism (PA), a large multinational trial shows.

The retrospective cohort study of 435 patients with PA who underwent adrenalectomy between 2010 and 2016 found 27.1% were cured and no longer needed antihypertensive medications, whereas a further 31% had clear improvement, defined as normotension with an equal or reduced number of antihypertensive medications.

There was a 25mmHg mean decrease in systolic blood pressure (SBP) among the clear improvement group, with a 48% decrease in daily defined dose of medications, researchers reported in JAMA Surgery.

For the 41.8% of patients who still had per­sistent hypertension after surgery, about 40% experienced a 10mmHg decrease in SBP or more without additional antihypertensives.

‘Every 10mmHg reduction in SBP leads to a risk reduction of 20% in major cardiovascular events, 17% in coronary heart disease, 27% in stroke, 28% in heart failure and 13% in all­ cause mortality,’ the researchers noted.

‘Combining these results shows that... 90% of patients had any form of decrease in BP and/ or number of hypertensive medications and, in a minimum of 73% of patients, we considered this decrease as clinically significant.’

Professor Michael Stowasser, Director of the University of Queensland’s Endocrine Hypertension Research Centre, noted the hypertension cure rates were considerably lower than the 60 to 80% his group would expect to see in practice.

‘This could relate to the fact that many of the patients were followed up for a relatively short period of time. We would recommend at least six to 12 months,’ he told Endocrinology Today.

The participating institutions used non­uniform diagnostic and management proto­cols, and the criteria used to define response to surgery were not standardised despite a 2017 paper offering clear-cut guidelines for assessing adrenalectomy outcomes, he added.

‘Nevertheless, the authors correctly point out that adrenalectomy in unilateral PA provides cure or improvement in hypertension in the majority of operated patients,’ he said.

Data showed about 5 to 10% of all new patients with hypertension will have PA, highlighting the need for routine screening.

‘PA should be actively sought and patients with unilateral forms identified so that they may be given the opportunity to enjoy the benefits of optimal management,’ Professor Stowasser said.

Adrenal venous sampling can differentiate the 30% of patients with PA with the unilateral form.
JAMA Surg 2019: e185842.