Primary Aldosteronism More Prevalent in Patients With Cardioembolic Stroke and Atrial Fibrillation

Van Nguyen, Tian Ming Tu, Marlie Jane B Mamauag, Jovan Lai, Seyed Ehsan Saffari, Tar Choon Aw, Lizhen Ong, Roger S Y Foo, Siang Chew Chai, Shaun Fones, Meifen Zhang, Troy H Puar, Van Nguyen, Tian Ming Tu, Marlie Jane B Mamauag, Jovan Lai, Seyed Ehsan Saffari, Tar Choon Aw, Lizhen Ong, Roger S Y Foo, Siang Chew Chai, Shaun Fones, Meifen Zhang, Troy H Puar

Abstract

Background: Primary aldosteronism (PA) is the most common cause of secondary hypertension, and patients are at an increased risk of atrial fibrillation (AF) and stroke. We assessed the prevalence of PA in patients with recent stroke.

Methods: We recruited 300 patients admitted to an acute stroke unit with diagnosis of cerebrovascular accident (haemorrhagic/ischaemic) or transient ischaemic attack. Three months post-stroke, plasma renin and aldosterone were measured. Patients with an elevated aldosterone-renin ratio proceeded to the confirmatory saline loading test.

Results: Twenty-six of 192 (14%) patients had an elevated aldosterone-renin ratio. Three of 14 patients who proceeded to saline loading were confirmed with PA (post-saline aldosterone >138 pmol/l). Another three patients were classified as confirmed/likely PA based on the markedly elevated aldosterone-renin ratio and clinical characteristics. The overall prevalence of PA amongst stroke patients with hypertension was 4.0% (95% confidence interval (CI): 0.9%-7.1%). Prevalence of PA was higher amongst patients with cardioembolic stroke, 11% (95% CI: 1.3%-33%), resistant hypertension, 11% (95% CI: 0.3%-48%), and hypertension and AF, 30% (95%CI: 6.7%-65%). If only young patients or those with hypokalaemia were screened for PA, half of our patients with PA would not have been diagnosed. Our decision tree identified that stroke patients with AF and diastolic blood pressure ≥83mmHg were most likely to have PA.

Conclusion: We found that amongst hypertensive patients with stroke, PA was more prevalent in those with AF, or cardioembolic stroke. Screening for PA should be considered for all patients with stroke.

Trial registration: ClinicalTrials.gov NCT03789357.

Keywords: atrial fibrillation; cerebrovascular accident; endocrine hypertension; hyperaldosteronism; secondary hypertension; transient ischaemic attack.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Nguyen, Tu, Mamauag, Lai, Saffari, Aw, Ong, Foo, Chai, Fones, Zhang and Puar.

Figures

Graphical Abstract
Graphical Abstract
Amongst patients with recent stroke, primary aldosteronism was more prevalent in those with atrial fibrillation, cardio-embolic stroke and resistant hypertension. Patients with primary aldosteronism had greater left ventricular mass and larger left atrial volume. Patients with good functional recovery after a stroke should be screened for primary aldosteronism.
Figure 1
Figure 1
Consort diagram of 300 patients with acute stroke recruited. *One patient did not require confirmatory testing in view of the elevated aldosterone–renin ratio and spontaneous hypokalemia; two patients had elevated aldosterone and elevated aldosterone–renin ratio and were started on spironolactone. ARR, aldosterone–renin ratio; CVA, cerebrovascular accident; GFR, glomerular filtration rate; PA, primary aldosteronism; SLT, saline-loading test; TIA, transient ischaemic attack.
Figure 2
Figure 2
Prevalence rate of primary aldosteronism in the entire cohort and various subgroups.
Figure 3
Figure 3
Decision tree model to predict the likelihood of primary aldosteronism in patients with recent stroke. AF, atrial fibrillation; DBP, diastolic blood pressure.

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