Tsai Cheng-Hsuan, Brown Jenifer M, Parisien-La Salle Stefanie, Newman Andrew J, Wu Vin-Cent, Lin Yen-Hung, Vaidya Anand
Center for Adrenal Disorders, Division of Endocrinology, Diabetes, and Hypertension, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (C.-H.T., J.M.B., S.P.-L.S., A.J.N., A.V.).
Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei (C.-H.T., Y.-H.L., A.V.).
Hypertension. 2025 Jun;82(6):1046-1055. doi: 10.1161/HYPERTENSIONAHA.125.24711. Epub 2025 Mar 31.
Primary aldosteronism (PA) is a distinct cause of low-renin hypertension (LRH), characterized by inappropriate aldosterone production. We investigated the distinction between LRH and PA by leveraging the physiological effects of angiotensin-converting enzyme inhibition.
We conducted a retrospective cohort study including 756 patients with LRH who underwent a captopril challenge test (CCT) for evaluation of PA. The distinction between PA and LRH was assessed using 4 CCT criteria: (1) Post-CCT plasma renin activity <1 ng/mL per hour and plasma aldosterone concentration decrease <30%; (2) Post-CCT aldosterone-to-renin ratio (ARR) >30 ng/dL per ng/mL per hour; (3) Post-CCT plasma renin activity <1 ng/mL per hour; and (4) Post-CCT plasma aldosterone concentration >11 ng/dL. Longitudinal outcomes following aldosterone-targeted therapy were assessed using the Primary Aldosteronism Surgery Outcome and Primary Aldosteronism Medical Outcome criteria.
There was a continuous spectrum of nonsuppressible aldosterone production post-CCT. When interpreting CCT results based on both renin and aldosterone responses (criteria 1 or 2), 57.8% to 66.3% of patients were classified as having PA. In contrast, when based on aldosterone or renin responses alone (criteria 3 or 4), 82.5% to 95.1% of patients were classified as having PA. Complete or partial treatment response rates following aldosterone-targeted therapy were high, ranging from 86.5% to 91.7%, regardless of CCT interpretation.
These findings highlight the blurred distinction between LRH and PA. Although persistently suppressed renin, or elevated aldosterone, following captopril facilitated the maximum capture of PA cases, the implementation of aldosterone-targeted therapy provided similar benefits to all patints, regardless of CCT interpretation. Empirical aldosterone-directed therapy for patients with LRH suspected of having PA may be an appropriate alternative to laborious diagnostics to confirm PA.
原发性醛固酮增多症（PA）是低肾素性高血压（LRH）的一个独特病因，其特征是醛固酮分泌异常。我们通过利用血管紧张素转换酶抑制的生理效应来研究LRH和PA之间的区别。
我们进行了一项回顾性队列研究，纳入了756例接受卡托普利激发试验（CCT）以评估PA的LRH患者。使用4项CCT标准评估PA和LRH之间的区别：（1）CCT后血浆肾素活性<1 ng/mL每小时且血浆醛固酮浓度下降<30%；（2）CCT后醛固酮与肾素比值（ARR）>30 ng/dL每ng/mL每小时；（3）CCT后血浆肾素活性<1 ng/mL每小时；（4）CCT后血浆醛固酮浓度>11 ng/dL。使用原发性醛固酮增多症手术结局和原发性醛固酮增多症药物治疗结局标准评估醛固酮靶向治疗后的纵向结局。
CCT后存在不可抑制的醛固酮分泌的连续谱。当根据肾素和醛固酮反应两者来解释CCT结果（标准1或2）时，57.8%至66.3%的患者被分类为患有PA。相比之下，当仅基于醛固酮或肾素反应（标准3或4）时，82.5%至95.1%的患者被分类为患有PA。无论CCT的解释如何，醛固酮靶向治疗后的完全或部分治疗反应率都很高，范围为86.5%至91.7%。
这些发现凸显了LRH和PA之间模糊的区别。尽管卡托普利治疗后肾素持续受抑制或醛固酮升高有助于最大限度地识别PA病例，但无论CCT的解释如何，实施醛固酮靶向治疗对所有患者都提供了类似的益处。对于疑似患有PA的LRH患者，经验性醛固酮导向治疗可能是替代繁琐诊断以确诊PA的合适选择。
