Correct Answer: A. Refer for surgical laparoscopic adrenalectomy.
Correct Answer: A. Refer for surgical laparoscopic adrenalectomy.
The patient underwent surgical laparoscopic adrenalectomy with close post-operative monitoring of aldosterone levels, serum electrolytes, and BP. Selection B is also reasonable if the patient is not a surgical candidate, however, this option should include monitoring of the adenoma.
Discussion. A recent cohort study investigated the cardiovascular outcomes of individuals with PA and age-matched controls with essential hypertension. Individuals with PA had higher rates of incident AF compared to those with essential hypertension. Furthermore, in patients with PA and inadequate mineralocorticoid blockade, there was a 2.6-fold higher risk of incident AF compared with those with PA and adequate mineralocorticoid receptor blockade or surgical adrenalectomy. The efficacy of mineralocorticoid receptor blockade was measured by assessing for a risk in serum renin activity level.5
Conclusion. The key takeaways from this case are (1) consider secondary causes in new-onset AF with uncontrolled hypertension, (2) recognize that hypokalemia is absent in most patients with PA, (3) when compared with essential hypertension, PA leads to more end-organ damage and increased AF rates, and (4) treatment options for PA include medical and surgical approaches tailored to individual patient factors.
References:
1. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(5):1889-916. doi:10.1210/jc.2015-4061
2. Rossi GP, Bernini G, Caliumi C, et al. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol. 2006;48(11):2293-300. doi:10.1016/j.jacc.2006.07.059
3. Hannemann A, Bidlingmaier M, Friedrich N, et al. Screening for primary aldosteronism in hypertensive subjects: results from two German epidemiological studies. Eur J Endocrinol. 2012;167(1):7-15. doi:10.1530/EJE-11-1013
4. Monticone S, D'Ascenzo F, Moretti C, et al. Cardiovascular events and target organ damage in primary aldosteronism compared with essential hypertension: a systematic review and meta-analysis. Lancet Diabetes Endocrinol. 2018;6(1):41-50. doi:10.1016/S2213-8587(17)30319-4
5. Hundemer GL, Curhan GC, Yozamp N, Wang M, Vaidya A. Incidence of atrial fibrillation and mineralocorticoid receptor activity in patients with medically and surgically treated primary aldosteronism. JAMA Cardiol. 2018;3(8):768-774. doi:10.1001/jamacardio.2018.2003