Targeted treatment of confirmed and suspected primary aldosteronism in Bangladeshi patients: a prospective outcomes study

Background Primary aldosteronism (PA) is the most common endocrine hypertension. It markedly increases cardiovascular risk, which is mitigated by targeted therapy. Current guidelines suggest mineralocorticoid receptor antagonist (MRA) therapy even for suspected PA cases not meeting strict diagnostic criteria. The impact of this recommendation on patient outcomes is unknown. Objective To assess clinical and biochemical effects of MRA therapy in patients with confirmed or suspected PA in a tertiary hospital in Bangladesh. Methods Consecutive hypertensive patients with an aldosterone-to-renin ratio (ARR) >50 pmol/mU underwent saline suppression (SST) and/or captopril challenge testing (CCT). PA was confirmed if post-SST aldosterone >170 pmol/L or post-CCT aldosterone >333 pmol/L. Subtyping relied on adrenal CT, as adrenal vein sampling was unavailable. All non-surgical patients received spironolactone regardless of suppression results. Response was evaluated at six months. Complete clinical response was defined as BP <140/90 mmHg on MRA monotherapy; complete biochemical response required normalized DRC >10 mU/L and serum potassium. Results Of 178 patients initiated on spironolactone, 175 completed follow-up. A complete clinical response occurred in 93 patients (53%). Baseline hypokalemia did not predict response. Notably, baseline aldosterone, renin, and ARR overlapped significantly across response categories. Over 50% of complete responders in the SST cohort and approximately 90% in the CCT cohort had post-test aldosterone levels below conventional diagnostic thresholds. Conclusions MRA therapy was effective in patients with both confirmed and suspected PA. These findings support a renin-guided, pragmatic approach to MRA therapy for aldosterone-mediated hypertension, particularly in resource-limited settings.