Response to More Fuel to the Debate on the “Epidemic of Primary Aldosteronism”
The data from the Primary Aldosteronism Prevalence in Italy Study, despite some problems, remain the largest experience for ascertaining the prevalence of primary hypertension.1 I will answer the claims by Rossi et al2 that I made “several inaccurate statements” in regard to these data.
First, the makeup of the population studied is not delineated in the original article. Even if none had resistant hypertension, the patients were almost certainly, at least in part, preselected by their primary physicians for referral to the study centers.
Second, the remarkable correlation between the 2 ARRs seen in primary aldosteronism prevalence in Italy is certainly the exception. I refer again to the cautions proposed by numerous investigators on the variability of responses.3,4
Third, the comparison by Rossi et al2 of the captopril and saline suppression test5 was published after my article was submitted. Despite their conclusion, errors with the captopril test continue to surface.6
Fourth, because only 43 of the 124 patients with PA had adrenal venous sampling, it is obvious that this “gold standard” was not used to differentiate aldosterone-producing adenoma from bilateral hyperplasia in the majority of patients. Mineralocorticoid scintigraphy, to my knowledge, has not been shown to be definitive, and all of the experts recognize the inaccuracies of computed tomography and MRI.
Fifth, PA is a “big deal” because it is a curable form of hypertension. However, the long-term follow-up of patients with PA who had surgery has clearly shown that they had no better outcome than those given medical therapy.7 The low doses of spironolactone needed rarely cause gynecomastia and, if breast enlargement is noted, other therapies can be used, particularly because eplerenone is now generic and should be widely available.
I appreciate that my position, counter to most who work in this field, may influence clinical practice. I hope so. I continue to believe that PA is much more rare than is now being claimed and should not be looked for in the majority of hypertensive subjects to save both money and patient discomfort.
Rossi GP, Bernini G, Caliumi C, Desideri G, Fabris B, Ferri C, Ganzaroli C, Giacchetti G, Letizia C, Maccario M, Mallamaci F, Mannelli M, Mattarello MJ, Moretti A, Palumbo G, Parenti G, Porteri E, Semplicini A, Rizzoni D, Rossi E, Boscaro M, Pessina AC, Mantero F. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol. 2006; 48: 2293–2300.
Rossi GP, Pessina AC, Mantero F. More fuel to the debate on the “epidemic of primary aldosteronism.” Hypertension. 2008; 51: e1–e2.
Hirohara D, Nomura K, Okamoto T, Ujihara M, Takano K. Performance of the basal aldosterone to renin ratio and of the renin stimulation test by furosemide and upright posture in screening for aldosterone-producing adenoma in low renin hypertensives. J Clin Endocrinol Metab. 2001; 86: 4292–4298.
Rossi GP, Belfiore A, Bernini G, Desideri G, Fabris B, Ferri C, Giacchetti G, Letizia C, Maccario M, Mallamaci F, Mannelli M, Palumbo G, Rizzoni D, Rossi E, gabiti-Rosei E, Pessina AC, Mantero F. Comparison of the captopril and the saline infusion test for excluding aldosterone-producing adenoma. Hypertension. 2007; 50: 424–431.
Mulatero P, Bertello C, Garrone C, Rossato D, Mengozzi G, Verhovez A, Fallo F, Veglio F. Captopril test can give misleading results in patients with suspect primary aldosteronism. Hypertension. 2007; 50: e26–e27.
Catena C, Colussi G, Lapenna R, Nadalini E, Chiuch A, Gianfagna P, Sechi LA. Long-Term cardiac effects of adrenalectomy or mineralocorticoid antagonists in patients with primary aldosteronism. Hypertension. 2007; 50: 911–918.