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John W. Funder, Aldosterone-Renin Ratios in the Context of Primary Care, The Journal of Clinical Endocrinology & Metabolism, Volume 89, Issue 9, 1 September 2004, Pages 4219–4220, https://doi.org/10.1210/jc.2004-1397
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When Jerome Conn first described primary aldosterone, he predicted that this syndrome may account for 20% of all essential hypertension. For the next 40 yr, conventional wisdom (and medical school teaching) reduced this figure to less than 1%. Over the last decade, however, studies from around the world have progressively revised the figure upward, toward (or in several cases beyond) the 20% level Conn predicted. In this issue of JCEM, Olivieri et al. (1) present their findings on an unselected population of hypertensives from a northern Italian general practice population. They find an elevated aldosterone to renin ratio (ARR), evidence for autonomous aldosterone secretion, in almost one third (32.4%) of their cases. In the process, the authors of this study raise a number of important questions in the area.
Before these questions are considered, it is important to point out a number of features of the Bussolengo study (1). First, the authors make a convincing case that their sample is representative, despite a surprisingly high 30% of established hypertensives declining venepuncture “for personal (business, working or family) reasons”; the extent to which 4 wk of medication withdrawal (except for verapamil and α-blockers) contributed to this fallout is not stated. Second, the criteria for establishing hypertension and the protocols used for blood sampling appear more than adequate. Third, the use of a plasma aldosterone to direct active renin ratio (AARR) rather than the more common plasma aldosterone to plasma renin activity ratio (ARR) appears to have been exhaustively validated by two previous studies involving direct comparison (n = 120) and case matching (AARR, n = 165; AAR, n = 309). Fourth, although the cut-off for AAR in other studies varies from 27 upward, the authors chose a conservative cut-off value, equivalent to more than 50 for AAR, as an index of elevated aldosterone to renin levels. Finally, the authors are careful to distinguish between elevations in aldosterone to renin ratio and primary aldosteronism; only a minority of the 32.4% of patients in fact had aldosterone levels above the normal range, to the extent to which such a range is useful.
