Arterial hypertension and cardiovascular disease – absolute aldosterone excess is the tip of the iceberg 1

Arterial hypertension is an important public health challenge worldwide. In Germany prevalence of arterial hypertension is around 55% and therefore much higher compared to other European countries and the USA. Approx 26% of all causes of death in Germany might be directly related to the consequences of an inadequately controlled blood pressure. Poor blood pressure control may be in part due to lack of awareness for potentially curable causes of hypertension. Primary aldosteronism (PA) in terms of an absolute excess of aldosterone is currently regarded as the most frequently curable cause of arterial hypertension. Prevalence of PA is 5%–12% in arterial hypertension and in 17%–23% in drug-resistant hypertension. These numbers suggest that around 1.2 million people in Germany might be affected by PA. Absolute excess of aldosterone is strongly associated with higher risk of the development and progression of coronary artery disease, left ventricular hypertrophy, sudden cardiac death, chronic kidney disease and strokes. The American Endocrine Society recommends screening for PA via determination of the aldosterone to renin ratio in selected subgroups of patients. Highly standardized screening procedures are warranted in order to avoid false-positive or false-negative screening results. Accumulating evidence, however, suggests that aldosterone might mediate cardiovascular damage independent of the presence of PA. Dietary salt excess, lower kidney function and increased oxidative stress are important prerequisites of aldosterone induced target organ damage. The association between relative excess of aldosterone and higher cardiovascular risk puts dietary salt restriction in the perspective of cardiovascular prevention medicine. In addition, further interventional studies are warranted to elucidate the beneficial effects of MR blockade in cardiovascular risk groups.