The article, “Primary Aldosteronism: Are We Missing the Wood for the Trees?” [1], to which Piaditis et al. refer [2], makes a series of 5 points. The first is that on the current estimates on the prevalence of hypertension, and of primary aldosteronism in hypertension, in no country worldwide are more than 1% of patients with primary aldosteronism diagnosed and treated. The second is that to diagnose primary aldosteronism in the remaining >99% of patients, and then appropriately manage them, is way beyond the available health care resources in any country. The third is that primary aldosteronism has a risk profile, in terms of atrial fibrillation, stroke, and nonfatal myocardial infarct, far higher than age-, sex-, and blood pressure-matched essential hypertension [3]. The fourth is that mineralocortoid receptor antagonism is safe, efficacious, and uniquely vasoprotective in essential hypertension when titrated to effect [4]
[5], specifically blood pressure lowering in resistant hypertension [6], and potentially game-changing in occult primary aldosteronism. The final point is the logical conclusion drawn from the first four – that a low dose mineralocortoid receptor antagonist should routinely be part of first line therapy in newly diagnosed hypertensives.
