Hyperaldosteronism: recent concepts, diagnosis, and management

As a cause for hypertension, aldosterone excess is now thought to be more prevalent than previously quoted in textbooks. Classical features of hypokalaemia and metabolic alkalosis can be absent even in the presence of marked hypertension. This implies the need for a high index of suspicion and possibly argues the case for routine screening, especially in patients with “difficult to treat” hypertension. Given multisystem target organ damage and increased cardiovascular risk associated with chronic uncontrolled hypertension, a readily treatable cause such as hyperaldosteronism is an important diagnosis to make. In addition, hyperaldosteronism related hypertension is now known to cover other recently identified monogenic disorders such as glucocorticoid remediable aldosteronism. These rarer monogenic hypertensive disorders provide clues to cracking the mystery behind polygenic “essential” hypertension. Apart from patients with hyperaldosteronism, a subset of the well recognised “low renin hypertension” patient group also appears to produce a dramatic and remarkable response when treated with spironolactone. We suggest that spironolactone sensitive hypertension may represent a wider spectrum of disorders where blood pressure is readily controlled by the addition of aldosterone receptor antagonist.