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Canadian Journal of Cardiology

Volume 28, Issue 3, May–June 2012, Pages 254-257
Canadian Journal of Cardiology

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Lessons From Africa: The Importance of Measuring Plasma Renin and Aldosterone in Resistant Hypertension

https://doi.org/10.1016/j.cjca.2011.11.010Get rights and content

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Cardiac and Vascular Effects of Aldosterone

Aldosterone is usually thought of in connection with its renal tubular effects, with retention of salt and water raising blood pressure, and excretion of potassium and magnesium affecting heart rhythm18 and the metabolic syndrome.19 However, there is strong evidence that aldosterone also aggravates heart failure by effects on myocardial extracellular matrix,20 and aggravates atherosclerosis, via inflammation and other effects on the artery wall.21, 22, 23, 24, 25 As reviewed recently by

Physiologically Individualized Therapy Based on Plasma Renin and Aldosterone

The management of resistant hypertension can be substantially improved by measuring plasma renin and aldosterone, to guide individualized therapy.37 The algorithm is described in Table 1.

A version of that approach was shown in a randomized controlled trial by Egan et al., to improve blood pressure control in a hypertension clinic in Charleston, South Carolina.38 The algorithm described in Table 1 is more specific because there are two main groups of low-renin hypertensive patients—those with

Conclusions

Measuring plasma aldosterone in addition to plasma renin adds importantly to management of resistant hypertension in two ways: (1) it permits identification of low-renin patients who have low levels of aldosterone because of Liddle's variants, who are specifically treated with amiloride; and (2) it identifies patients with high levels of plasma aldosterone, who would benefit from aldosterone antagonism, not only to achieve control of their hypertension, but to minimize the direct adverse

Disclosures

The author has received grants and/or research support from HSF, NIH, CIHR, and Merck; honoraria for lectures from Merck, Boehringer-Ingelheim, and Bayer; consulting fees from Novartis and Boehringer-Ingelheim; and has an interest in www.vascularis.com.

The author's group is testing the possibility that eplerenone may slow progression of carotid atherosclerosis in a study funded by HSF Ontario; this is supported in part by donation of study drug and placebo by Pfizer Inc. An application has been

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      Simply adding a diuretic might have been all that was required. The algorithm described in Table 2 is used as follows: low renin/high aldosterone patients (a primary aldosteronism phenotype) are best treated with aldosterone antagonists; low renin/low aldosterone patients (a Liddle phenotype) are best treated with amiloride,7 and high renin/high aldosterone patients are best treated with angiotensin receptor blockers.7 For primary aldosteronism surgery is rarely indicated, because most primary aldosteronism (particularly in black individuals7) is probably from bilateral hyperplasia.

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      That persons of African ancestry are more likely to have apparent treatment-resistant hypertension and specific associated pathophysiology of hypertension (ie, low-renin hypertension, etc) has been suggested as a major contributor to the black–white stroke disparity.37 Therefore, especially in blacks, it is recommended that physicians take an individualized approach to assess and manage BP levels, including additional diagnostic evaluations including measurement of plasma renin, aldosterone-changing medications, and incorporating advice related to lifestyle changes.19,38 The supplemental analysis restricted to those taking diuretic medication showed a substantial mediation of the risk in blacks, suggesting that treatment with diuretics may be a key to this individualized approach.

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