Is there an unrecognized epidemic of primary aldosteronism? (Pro)
Is there an unrecognized epidemic of primary aldosteronism? (Pro)
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DOI：
10.1161/hypertensionaha.106.086116
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发表时间：
2007-09-01
期刊：
影响因子：
8.3
通讯作者：
Calhoun, David A.
中科院分区：
文献类型：
--
作者：
Calhoun, David A.
447个病人。同样，计算机断层扫描或MRI缺乏足够的敏感性和特异性来识别罪犯肾上腺腺瘤。13因此，在大多数PA病例中，肾上腺静脉取样（AVS）是必要的，以确定与单侧阿帕（或罕见的单侧增生）一致的醛固酮分泌的偏侧化，然后进行手术切除和病理检查以明确确认阿帕。考虑到AVS和肾上腺切除术的成本、技术难度和相关风险，将这2种手术纳入评估PA患病率的研究是不可行的，最近有1例例外。因此，PA患病率的最新估计将包括两种亚型，即特发性和真正的康恩综合征。特发性PA和继发于肾上腺腺瘤的PA之间的区别不仅具有生理重要性，而且在临床上也具有相关性，因为特发性PA不适于手术矫正，因此，长期使用药物，特别是盐皮质激素受体拮抗剂，通常是必要的。相比之下，继发于阿帕的PA患者通常从肾上腺切除术中获益，通常允许剂量下调甚至完全停用钾补充剂和/或抗高血压药物。因此，虽然从机理的角度来看，醛固酮过量在引起高血压中所起的作用是相当令人感兴趣的，但从临床的角度来看，重要的是筛选醛固酮过量在指导治疗中所起的作用。虽然相对便宜，一般容易做到，常规测量ARR在所有或选定的高血压患者中是否有治疗益处，或者我们是否应该保留这种筛查仅用于我们将继续评估的患者，只要AVS和肾上腺切除术，如果阿帕是可疑的？在认识到以前的研究有时会有局限性，会导致高估PA患病率，我希望不一定解决，但至少推进目前的讨论，通过审查最近的研究，特别是避免了这些相同的方法学缺陷，从而提供新的见解PA的真实患病率。在这样做的过程中，我希望能够改善临床指导，以了解何时以及如何筛选醛固酮过量的证据。
447 patient basis. Likewise, computed tomography or MRI lacks sufficient sensitivity and specificity to identify culprit adrenal adenomas. 13 Accordingly, in most cases of PA, adrenal vein sampling (AVS) is necessary to identify lateralization of aldosterone secretion consistent with a unilateral APA (or, rarely, unilateral hyperplasia) followed by surgical resection and pathological examination to definitively confirm an APA. Given the costs, technical difficulty, and associated risks of AVS and adrenalectomy, it has not been feasible, with 1 recent exception, to include these 2 procedures into studies assessing the prevalence of PA. Accordingly, the recent estimates of PA prevalence would have included both subtypes, that is, idiopathic and true Conn’s syndrome. The distinction between idiopathic PA and PA secondary to an adrenal adenoma is not just of physiological importance but is also clinically relevant in that idiopathic PA is not amendable to surgical correction, and, therefore, long-term use of pharmacological agents, specifically including mineralocorticoid receptor antagonists, is generally necessary. In contrast, patients with PA secondary to an APA do generally benefit from adrenalectomy, often allowing for down titration or even complete withdrawal of potassium supplements and/or antihypertensive agents. Therefore, whereas the role that aldosterone excess is playing in causing hypertension is of considerable interest from a mechanistic perspective, from a clinical perspective, what is important is what role screening for aldosterone excess has in guiding therapy. Although relatively inexpensive and generally easy to do, is there therapeutic benefit in routinely measuring an ARR in all or selected hypertensive patients or should we reserve such screening only for patients in whom we would continue the evaluation as far as AVS and adrenalectomy if an APA was suspected?In recognizing that previous studies have sometimes had limitations that would have resulted in overestimates of PA prevalence, I hope not necessarily to resolve but to at least advance the current discussion by reviewing recent studies that have specifically avoided these same methodologic shortcomings and, thus, provide new insight into the true prevalence of PA. In doing so, I hope to allow for improved clinical guidance as to when and how to screen for evidence of aldosterone excess.