In patients with primary hyperaldosteronism, the goal of treatment is to prevent the morbidity and mortality associated with hypertension and hypokalemia. The appropriate treatment depends on the cause (Conn syndrome vs IHA). Although hypertension is frequently cured after unilateral adrenalectomy in patients with Conn syndrome, the mean cure rate is only 19% after unilateral or bilateral adrenalectomy in patients with IHA, in whom treatment mainly is medical.
In the case of APA, medical therapy is used preoperatively to control blood pressure and correct hypokalemia, thus decreasing surgical risk. Medical therapy is administered to patients with persistent hypertension postoperatively, poor surgical candidates, and those who refuse surgery.
A sodium-restricted diet (<80 mEq or <2 g of sodium per d), maintenance of ideal body weight, and regular aerobic exercise contribute substantially to the success of pharmacologic treatment.
Frequently, hypertension and hypokalemia can be controlled with a potassium-sparing agent (first-step agent) such as spironolactone. Hypokalemia is promptly corrected, but hypertension may take as long as 4-8 weeks to correct. Potassium supplementation should not be routinely administered with spironolactone because of the potential for the development of hyperkalemia. If hypertension persists despite titration, a second-step agent is added to the treatment.
Second-step agents include thiazides diuretics, ACE inhibitors, calcium channel antagonists, and angiotensin II blockers.
GRA is treated with physiologic doses of glucocorticoid, which correct the hypertension and hypokalemia.
Surgical Care
Surgery is the main therapy for Conn syndrome. A laparoscopic adrenalectomy is favored, when possible.
In patients with Conn syndrome, the blood pressure response to spironolactone preoperatively is a predictor of the blood pressure response to unilateral adrenalectomy.
Surgical risk can be decreased by correcting the hypokalemia and controlling the blood pressure by administering spironolactone for at least 1-2 weeks, preferably 6 weeks, before surgery.
Hypertension typically does not resolve immediately postoperatively but, rather, over 3-6 months; however, almost all patients have improved control of blood pressure after surgery. Long-term cure rates with unilateral adrenalectomy for Conn syndrome average 69%. Persistent hypertension may be related to resetting of baroreceptors, established hemodynamic changes, structural changes in the blood vessels, or coincidental essential hypertension.