Marzano Luigi, Zoccatelli Francesca, Pizzolo Francesca, Friso Simonetta
Department of Medicine, Unit of Internal Medicine B, University of Verona School of Medicine, Azienda Ospedaliera Universitaria Integrata Verona, Italy.
Hypertension. 2025 Aug;82(8):e142-e153. doi: 10.1161/HYPERTENSIONAHA.125.25104. Epub 2025 Jun 25.
Primary aldosteronism (PA) is a common curable cause of secondary hypertension that significantly increases left ventricular mass (LVM) and predisposes patients to adverse cardiovascular outcomes. Although adrenalectomy and medical therapy with mineralocorticoid receptor antagonists (MRAs) are both used to treat PA, their long-term comparative efficacy in reversing cardiac structural changes remains debated.
We systematically searched MEDLINE and Embase for prospective and retrospective clinical trials published up to November 22, 2024, with a minimum follow-up of 6 months that reported changes in LVM in patients with PA treated with adrenalectomy or MRAs. Data were independently extracted by 2 reviewers, and risk-of-bias assessments were conducted using standardized tools. The primary outcome was the percentage reduction in indexed LVM; secondary outcomes included changes in cardiac remodeling, and systolic and diastolic function parameters.
Seventeen studies comprising 1696 patients (49% adrenalectomy, 51% MRA therapy) were analyzed. Adrenalectomy yielded a significantly greater indexed LVM reduction (mean difference, -3.5% [95% CI, -4.9% to -2.2%]; <0.0001) and a 32% reduction in left ventricular hypertrophy risk ratio, compared with a 19% reduction with MRAs. Meta-regression revealed that shorter hypertension duration predicted greater LVM regression following adrenalectomy, whereas high dietary sodium attenuated MRA effects. In addition, left ventricular ejection fraction improved modestly after adrenalectomy.
Adrenalectomy provides superior long-term regression of LVM and left ventricular hypertrophy compared with MRAs in PA, supporting its use as the first-line treatment for unilateral PA. Future research should compare emerging nonsteroidal MRAs and aldosterone synthase inhibitors to further optimize cardiac remodeling outcomes.
原发性醛固酮增多症（PA）是继发性高血压的常见可治愈病因，可显著增加左心室质量（LVM），并使患者易发生不良心血管结局。虽然肾上腺切除术和使用盐皮质激素受体拮抗剂（MRA）进行药物治疗均用于治疗PA，但它们在逆转心脏结构变化方面的长期比较疗效仍存在争议。
我们系统检索了MEDLINE和Embase，以查找截至2024年11月22日发表的前瞻性和回顾性临床试验，这些试验的最小随访时间为6个月，报告了接受肾上腺切除术或MRA治疗的PA患者LVM的变化。数据由2名 reviewers 独立提取，并使用标准化工具进行偏倚风险评估。主要结局是指数化LVM的降低百分比；次要结局包括心脏重塑以及收缩和舒张功能参数的变化。
分析了17项研究，共1696例患者（49%接受肾上腺切除术，51%接受MRA治疗）。与MRA治疗使LVM降低19%相比，肾上腺切除术使指数化LVM显著降低更多（平均差异为-3.5%[95%CI，-4.9%至-2.2%]；<0.0001），左心室肥厚风险比降低32%。Meta回归显示，高血压病程较短预示肾上腺切除术后LVM逆转程度更大，而高钠饮食会减弱MRA的效果。此外，肾上腺切除术后左心室射血分数有适度改善。
在PA患者中，与MRA相比，肾上腺切除术能使LVM和左心室肥厚得到更好的长期逆转，支持将其作为单侧PA的一线治疗方法。未来的研究应比较新出现的非甾体MRA和醛固酮合酶抑制剂，以进一步优化心脏重塑结局。
