Atrial Fibrillation in Primary Aldosteronism

Abstract

Primary aldosteronism (PA) is the most common cause of secondary hypertension. Increasing evidence has demonstrated an increased cardiovascular risk in patients with PA compared to those with essential hypertension (EH), including atrial fibrillation (AF), the most prevalent arrhythmia among adults that is associated with an elevated risk of subsequent cerebro-cardiovascular adverse events. The mechanisms of increased prevalence of AF in PA patients are complex. Excessive aldosterone production is regarded to be a key component in the pathogenesis of AF, in addition to arterial hypertension and electrolyte imbalance. In addition, several translational and clinical studies have reported that structural remodeling with atrial fibrosis and electrical remodeling with arrhythmogenicity induced by an excess of aldosterone also play major roles in AF genesis. Clinical studies from several registries and meta-analysis have reported an increased prevalence and risk of AF in PA patients compared to EH patients. Recent trials have further demonstrated a reduction in the risk of new-onset atrial fibrillation (NOAF) after adrenalectomy, while the results of medical treatment with mineralocorticoid receptor antagonists (MRAs) have been inconsistent. This review outlines the current evidence of the relationship between PA and AF, and highlights recent progress in the management of PA with regards to the development of AF.

New-Onset Atrial Fibrillation in Patients With Primary Aldosteronism Receiving Different Treatment Strategies: Systematic Review and Pooled Analysis of Three Studies

“…Atrial fibrillation is associated with increased risks of stroke, heart failure and mortality (28). Excessive aldosterone is a major contributing factor to atrial fibrillation genesis (9,12), as shown in the German Conn's Registry which reported a prevalence rate of atrial fibrillation of 7.1% among 553 PA patients (29). Seccia et al also demonstrated that the PA was highly prevalent in hypertensive patients with unexplained atrial fibrillation in prospective appraisal on the prevalence of primary aldosteronism in hypertensive (PAPPHY) study (30).…”

“…Some clinical studies have shown that aldosterone induces left ventricular hypertrophy and fibrosis which is associated with left ventricular diastolic dysfunction (8,(36)(37)(38)(39)(40). The left ventricular diastolic dysfunction has a prominent influence on atrial structure and function which also contributed to the atrial fibrillation genesis (8,12,41).…”

“…Atrial fibrillation is associated with increased risks of stroke, heart failure and mortality ( 28 ). Excessive aldosterone is a major contributing factor to atrial fibrillation genesis ( 9 , 12 ), as shown in the German Conn’s Registry which reported a prevalence rate of atrial fibrillation of 7.1% among 553 PA patients ( 29 ). Seccia et al.…”

“…The MRA also significantly reduced new-onset atrial fibrillation and recurrent atrial fibrillation in general patient population in one recent meta-analysis ( 31 ). However, the interactions among hypertension, hyperaldosteronism, and atrial fibrillation genesis in PA patients are complex ( 9 , 12 ).…”

“…Atrial fibrillation is the most prevalent arrhythmia among adults that is associated with cerebro-cardiovascular complications ( 12 , 13 ). The prevalence of atrial fibrillation has been reported to be 1.1% in adults aged above 35 years in Taiwan ( 14 ).…”