Adequate Medical Management of Hyperaldosteronism Carries a Risk of Adverse Outcomes Comparable to Surgical Management

Objective: Primary hyperaldosteronism (PA), once considered as rare cause of hypertension, is a leading cause of secondary hypertension. When compared to essential hypertension, PA is associated with high rates of cardiovascular diseases and all-cause mortality. Despite the recent advances in PA research, the optimal therapy of choice remains unknown. Some observational studies from single clinics and with short follow-ups have suggested that adrenalectomy may lead to lower all-cause mortality compared to medical management. However, the long-term outcomes of medical versus surgical management in a nationwide patient sample with extended follow-up remain unclear. Design and method: We used data from the FinnGen register-based database that includes nationwide information on diagnoses, procedures, and laboratory values over several decades from 52021 individuals. We identified 1001 participants with a PA diagnosis who were divided into two subgroups: PA without (N=823) and with (N=178) adrenalectomy. We assessed the association between therapy of choice with three adverse outcomes (cardiovascular disease, major adverse cardiovascular events, and arrythmia) using multivariable-adjusted Cox models. We also examined the links between mean post-diagnosis potassium levels and adverse events in a subgroup with potassium data available (N=606). Results: Therapy of choice was not associated with any of the adverse outcomes in the age- and sex-adjusted (P>0.12 for all) or the multivariable-adjusted (P>0.19 for all) analyses (Figure). However, we observed a significant multivariable-adjusted association between potassium levels and incident arrhythmia in the medical therapy group (HR per 1 mmol increase in potassium 0.49; 95% CI 0.24-1.00; P=0.049) and in the whole study sample (HR 0.52; 95% CI 0.28-0.97; P=0.038). Conclusions: Our findings indicate that adequate medical management of PA, with avoidance of hypokalemia, leads to outcomes comparable to those of surgery.