Cardiac Structure and Function Across the Spectrum of Aldosteronism: the Atherosclerosis Risk in Communities Study

Abstract

Background: Aldosterone production and mineralocorticoid receptor activation are implicated in myocardial fibrosis and cardiovascular events. Methods: Cardiac structure and function were assessed in 4547 participants without prevalent heart failure (HF) in the ARIC study (Atherosclerosis Risk in Communities), with echocardiography, aldosterone, and plasma renin activity measurement (2011–2013). Subjects were characterized by plasma renin activity as suppressed (≤0.5 ng/mL per hour) or unsuppressed (>0.5 ng/mL per hour). Cross-sectional relationships with cardiac structure and function, and longitudinal relationships with outcomes (HF hospitalization; HF and all-cause death; HF, death, myocardial infarction, and stroke; and incident atrial fibrillation) were assessed. Models were adjusted for demographic and anthropometric characteristics and additively, for blood pressure and antihypertensives. Results: Evidence of primary aldosteronism physiology was prevalent (11.6% with positive screen) and associated with echocardiographic parameters. Renin suppression was associated with greater left ventricular mass, left ventricular volumes, and left atrial volume index, and a lower E/A ratio (adjusted P <0.001 for all). Higher aldosterone was associated with greater left ventricular mass and lower global longitudinal strain and lateral E′. The highest tertile of aldosterone was associated with a hazard ratio of 1.37 (95% CI, 1.06–1.77; 5.5-year follow-up) for incident atrial fibrillation relative to the lowest. Renin suppression was associated with HF (hazard ratio, 1.34 [95% CI, 1.05–1.72]; 7.3-year follow-up), although these relationships did not remain statistically significant after additional adjustment for hypertension. Conclusions: Renin suppression and aldosterone excess, consistent with primary aldosteronism pathophysiology, were associated with cardiac structural and functional alterations and may represent an early target for mitigation of fibrosis with mineralocorticoid receptor antagonists.

Higher plasma aldosterone is associated with increased risk of cardiovascular events in hypertensive patients with suspected OSA: UROSAH data

“…Nonetheless, differences in PAC levels among ethnic or racial entities also affect the stability and extrapolation of the results. Some previous findings have suggested that PAC were associated with cardiac structural and increased risk of allcause mortality in renin-suppressed group (15,29). Our stratified analysis shows whether renin is suppressed or not (≤0.5 or >0.5ng/ml per h), elevated PAC is independently associated with an increased risk of CVD.…”

Subclinical HMOD in Hypertension: Left Ventricular Diastolic Dysfunction

“…In a recent study, renin-independent aldosterone production was associated with alterations of cardiac structure and diastolic function, as assessed among the participants to the ARIC (the Atherosclerosis Risk in Communities Study) cohort. Renin suppression was associated with greater LV mass, LV volumes, LA volume index, and a lower E/A ratio (adjusted P < 0.001 for all), while higher aldosterone was associated with greater LV mass, lower global longitudinal strain and lateral E' [ 38 ].…”

Aldosterone and Cardiovascular Damage: a New Lesson From an Old Study

“…Those observations triggered a broader screening of patients with hypertension for PA and led to appreciate that, under high sodium intake, excess aldosterone damages the heart even when renin is undetectable. Since then, more consideration has been devoted to assessing hypertension-mediated organ damage in low-renin patients and the latest guidelines list hypertension-mediated organ damage in excess of what expected on the basis the degree of BP elevation among the conditions that should alert physicians on the presence of PA. 12 Owing to the current aging of the population, the clinical outcomes associated with aldosteronism identified in the study by Brown et al, 1 that is, atrial fibrillation and heart failure, contribute substantively to cardiovascular morbidity and mortality. The novel ARIC findings would suggest that renin and aldosterone profiling is valuable for risk stratification in clinical practice.…”

“…In a post hoc analysis of the Atherosclerosis Risk in Communities (ARIC) study, which recruited 15 792 adults (18.1% Black and 81.9% Whites), aged 45 to 64 years, from 4 US communities between 1987 and 1989, Brown et al 1 collected echocardiographic data, plasma renin and aldosterone values at visit 5 (2011–2013) and incident events at follow-up over 6 to 8 years in 4457 subjects entailing 28% of the original cohort. They observed an association of renin suppression with greater left ventricular (LV) mass index, LV volumes, altered LV filling, and left atrial volume index; of note, this increase of LV mass index entailed an eccentric LV remodeling, in line with previous observations in patients with primary aldosteronism (PA), who showed an inward reverse type of remodeling after cure by adrenalectomy.…”

“…Owing to the current aging of the population, the clinical outcomes associated with aldosteronism identified in the study by Brown et al, 1 that is, atrial fibrillation and heart failure, contribute substantively to cardiovascular morbidity and mortality. The novel ARIC findings would suggest that renin and aldosterone profiling is valuable for risk stratification in clinical practice.…”