Primary hyperaldosteronism natural history, complications and prognosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]

If left untreated, patients with primary hyperaldosteronism may progress to develop stroke, coronary artery disease, and renal insufficiency with associated proteinuria. Aldosterone producing adenomas (APAs) continue to grow slowly over time. The aldosterone production likely correlates with the size of the adenoma. It is a progressive disease and its common complications include left ventricular hypertrophy due to chronic hypertension, atrial fibrillation, myocardial infarction, stroke, proteinuria, and metabolic syndrome. The prognosis of primary hyperaldosteronism is good with treatment. Without treatment, primary hyperaldosteronism will result in hypertension with resultant hypertension-related complications, which may be a major cause of morbidity and mortality among patients.

• Primary hyperaldosteronism without treatment, leads to progressive increase in disease severity, eventually leading to involvement of both adrenals.^[1]
• If left untreated, patients with primary hyperaldosteronism may progress to develop severe resistant hypertension leading to stroke, coronary artery disease, and renal insufficiency with associated proteinuria.^[2]

Primary aldosteronism is characterized by the development of the following complications:^{[3][4][5][6][7][8]}

Cardiovascular complications

• Left ventricular hypertrophy
• Myocardial infarction
• Atrial fibrillation

Neurological complications

• Stroke^[7]
• Hypertensive encephelopathy

Renal complications

• Proteinuria including microalbuminuria^[9]
• Renal cysts^[10]

Metabolic complications

• Metabolic syndrome^[11][12][13]
• Diabetes mellitus^[5][8]

• The prognosis of primary hyperaldosteronism is good with treatment. Without treatment, primary hyperaldosteronism will result in hypertension with resultant hypertension-related complications, which may be a major cause of morbidity and mortality among patients.
• Adrenalectomy lowers long-term all-cause mortality from primary hyperaldosteronism.^[14][15][16]

Patients undergoing unilateral adrenalectomy for unilateral adenoma

• Adrenalectomy leads to cure of hypertension in 50% to 60% of patients.^[17][18]
• Blood pressure typically becomes normal after 1 to 6 months of the procedure.^[19]
• Treatment leads to a significant increase in quality of life and improved cardiovascular outcomes.

Patients receiving aldosterone antagonist medications

• Hypertension is controlled in majority of the patients.^[17][18]
• Improvement is not as significant as adrenalectomy for unilateral lesions.

Patients with FH-I undergoing treatment with glucocorticoid medications

• Hypertension in familial hyperaldosteronism type I (FH-I) is usually of early onset and may be severe enough to cause early death, usually from hemorrhagic stroke, unless specifically treated.^[20]
• Treatment with glucocorticoids, given in low doses is usually effective in controlling hypertension and consequently preventing stroke.

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