Most patients with primary aldosteronism undergoing adrenalectomy saw reductions in blood pressure, with some showing complete resolution of hypertension, a retrospective cohort study indicated.
In a global cohort of 435 patients with primary aldosteronism caused by an aldosterone-producing adenoma, 58% of patients showed clear improvement or total cure of hypertension after unilateral adrenalectomy, Menno Vriens, MD, of the University Medical Center Utrecht in the Netherlands, and colleagues reported in JAMA Surgery.
The other 42% were deemed as having “no clear success” after adrenalectomy because the benefits of surgery weren’t so apparent, as most of these patients (91%) had persistent postoperative hypertension.
Despite missing the threshold for “clear success,” however, this subgroup of patients still saw benefits, including a significant decrease in blood pressure — by a mean 9 mm Hg in systolic pressure and 3 mm Hg in diastolic pressure. These patients also required fewer antihypertensive medications, needing only two medications on average after surgery versus three before.
“Although this study shows complete clinical cure in only approximately one-quarter to one-third of the included patients, most patients became normotensive while receiving lower or equal use of antihypertensive medications,” Vriens and colleagues wrote. They also pointed to a previous study indicating that this magnitude of reduction “should be considered clinically relevant because every 10-mm Hg 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 analysis included patients from the U.S., Europe, Canada, and Australia who underwent unilateral adrenalectomy after confirmation of an aldosterone-producing adenoma by computer tomography, MRI, or adrenal venous sampling. About 60% of patients had a left adrenal tumor. Most patients underwent laparoscopic transabdominal adrenalectomy or endoscopic posterior retroperitoneal adrenalectomy; endoscopic lateral retroperitoneal adrenalectomy was less common.
Cure was defined as postoperative normotension — systolic blood pressure <140 and diastolic blood pressure <90 mm Hg without medication -- while clear improvement was normal blood pressure while receiving a lower or equal number of antihypertensive medications.
In an accompanying commentary, Heather Wachtel, MD, and Rachel Kelz, MD, MSCE, MBA, both of the Hospital of the University of Pennsylvania, suggested that clinical improvement might have been underestimated in the study.
“Within the cohort, 5% of patients had aldosterone-renin ratios not consistent with [primary aldosteronism],” they noted. Moreover, follow-up was relatively short (less than a month for 23% of patients and less than 3 months for nearly one-third), whereas physiologic response time following an adrenalectomy is normally 6-12 months. And, they suggested, some patients classified as “no clear success” did show reductions in blood pressure that would predict less risk of cardiovascular events.
Overall, they concluded, Vriens and colleagues may have been too conservative in their report, as “the precision of the presented data is obscured and the outcomes likely underestimate the outcomes of the treatment.”
Wachtel and Kelz urged that standardized outcome criteria be developed for evaluating treatment for primary aldosteronism.
Study authors and the editorialists declared they had no conflicts of interest.