Envoi

Authors: John Funder

Publish Date: 2011/04/12

Volume: 12, Issue: 1, Pages: 53-54

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Abstract

As most readers know the weight of scientific and clinical opinion around the world is that approximately one in ten patients with hypertension has primary aldosteronism What is understandable given two determinants of how we approach this issue is that our focus has been very narrow The first is that aldosterone is ‘disputed territory’ living in the marches rather than the mainstream—discovered by a physiologist and biophysicist characterized by nephrologists embraced by endocrinologists and much more recently cardiologists and on occasion by clinical pharmacologists The second is that the realization that this ~10 of hypertension reflects autonomous aldosterone secretion is relatively recent and on occasion turning round medical opinion and clinical practice is like turning round the Queen MaryOne upshot of this is that the focus among the informed and expert practitioners has been squarely on diagnosis and management an approach that might seem to reflect the historic teaching that primary aldosteronism is both a rare and relatively benign form of hypertension Neither of these is palpably the case the contribution of my good friend Norman Kaplan notwithstanding and what this does in my opinion is underscore the need to refocus our attention and energyIf 30 of the population in many countries with highly developed health care systems are hypertensive and 10 of these have primary aldosteronism we are faced with hundreds of thousands in lightly populated countries such as Australia and millions with primary aldosteronism elsewhere It is currently inconceivable that such numbers can be screened for autonomous aldosterone secretion at least until the development of simple accurate and cheap pointofcare methodology Subsequent exclusion/confirmatory testing not to mention adrenal venous sampling are even more inconceivable whether privately or publically funded given the numbers involvedGiven the impossibility of optimally managing all but a tiny proportion of cases in even advanced countries and the utility of mineralocorticoid receptor blockade in essential hypertension to advocate low dose spironolactone or eplerenone as firstline treatment in combination with standard antihypertensives for all hypertensive patientsIn public health terms the first two of these are of overwhelming importance and essentially the realm of medical education and politics As such they may be more difficult and less interesting than the latter two suggestions this should not however detract from what needs to become the main game for primary aldosteronism in the second and subsequent decades of the 21st century It’s now primarily a problem of public health

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