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Dr. Günther Egidi
Family physician
Responsible for medical education
German College of General Practitioners and Family Physicians (DEGAM)
Huchtinger Heerstr. 24
D 28259 Bremen
Phone: 0047 - 421 - 9888280
Fax: 0047 - 421 - 98882828
Germany
[email protected]
Prof. Guido Schmiemann
Family physician
Responsible for quality improvement
German College of General Practitioners and Family Physicians (DEGAM)
Georgstr. 9
D 27283 Verden
Phone: 0047 - 4231 - 928888
Fax: 0047 - 4231 - 9288890
Germany
[email protected]
Klaus Gebhardt, Family Physician, Neuwieder Str. 13
D 28325 Bremen
Phone: 0047 - 421 - 429213
Fax: 0047 - 421 - 406487
Germany
[email protected]
Recommendations for screening crucially depend on the diagnostic and therapeutic setting. We do not agree with the authors' statement aldosteronism being "a relatively common cause of resistant hypertension worldwide". The same as with the recommendation to test all patients with uncontrolled hypertension despite of the use of three BP lowering drugs. Three studies of unselected/primary care hypertension were included in the authors’ review. Two of them were about an outpatient clinic of a hospital[1] and of a hypertension center respectively[2]. The third study[3] was conducted in a hypertension clinic. It is written that 350 unselected adult hypertensive patients were examined. We are sure, however, that there was a selection effect compared with a "normal family practice office".
Impressed by a case of a patient whose hypertensive crises stopped after an operation of a Conn's tumor we conducted an evaluation[4] of all hypertensive patients in 2 German general practices. In this study there were was no selection , as all hypertensive patients were included.
Of 3107 patients visiting the practices, 564 were diagnosed with hypertension, 79 with criteria for resistant hypertension. Aldosteron – Renin – Ratio (ARR) could be measured in 63/79. We found only 2 cases of aldosteronism.
The percentage rates are too low (1 per mill of all patients - or 0.5% of all patients with hypertension - or 3.8% of those with resistant hypertension) to be denominated as "common cause". Some other questions remain regarding the recommendation to search for aldosteronism: why is it necessary to conduct a Renin-Aldosteron-ratio-test? Why not simply treat those patients with spironolactone whose ability to lower blood pressure is well proven[5]? Is it cost effective to do this lab exam?
Just recently new evidence was found for a lower prevalence of aldosteronism than suggested: a Dutch authors' group discovered a prevalence of 2,6% of all patients with elevated ARR but only 0,24% of all patients with newly diagnosed hypertension[6]!
References:
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[1] Omura M, Saito J, Yamaguchi K, et al. Prospective study on the prevalence of secondary
hypertension among hypertensive patients visiting a general outpatient clinic in Japan. Hypertens
Res 2004;27:193-202.
[2] Fogari R, Preti P, Zoppi A, et al. Prevalence of primary aldosteronism among unselected
hypertensive patients: a prospective study based on the use of an aldosterone/renin ratio above
25 as a screening test. Hypertens Res 2007;30:111-7
[3] Loh KC, Koay ES, Khaw MC, et al. Prevalence of primary aldosteronism among Asian hypertensive
patients in Singapore. J Clin Endocrinol Metab 2000;85:2854-9.
[4] Schmiemann G, Gebhardt K, Hummers-Pradier E, Egidi G Prevalence of Hyperaldosteronism in
Primary Care Patients with Resistant Hypertension J Am Board Fam Med 2012;25: 98–103
[5] Batterink J, Stabler SN, Tejani AM, Fowkes CT Spironolactone for hypertension The Cochrane
Library 2010, Issue 8
[6] Käyser SC, Deinum J, de Grauw W et al. Prevalence of primary aldosteronism in primary care: a
cross-sectional study Br J Gen Pract 2018; DOI: https://doi.org/10.3399/bjgp18X694589