Evaluating the impact of adrenalectomy and mineralocorticoid receptor antagonists for primary aldosteronism on left ventricular remodeling: a systematic review and meta-analysis

BACKGROUND: Primary aldosteronism (PA) is characterized by autonomous aldosterone production, which leads to left ventricular (LV) remodeling and adverse cardiovascular outcomes. This meta-analysis aimed to compare the effects of two treatment strategies, mineralocorticoid receptor antagonists (MRAs) and adrenalectomy, on the regression of LV remodeling in patients with PA. METHODS: Embase, PubMed, and Cochrane Library were searched for studies reporting the effect of adrenalectomy or medical therapy on reversing LV mass index (LVMI) in patients with PA. The outcome of interest was the reduction in LVMI after treatment. RESULTS: A total of 1197 patients with PA from 10 studies were included in the analysis. The meta-analysis demonstrated that both adrenalectomy and MRAs improved LVMI in patients with PA (adrenalectomy: standardized mean difference [SMD] = -0.49, 95% CI = -0.65 to -0.33; MRAs: SMD = -0.35, 95% CI = -0.48 to -0.22). The reduction in LVMI was greater following adrenalectomy in direct comparison analyses (difference-in-differences SMD = -0.15, 95% CI = -0.26 to -0.03). However, the effect size was small, and the impact of MRA optimization could not be assessed. In studies focusing specifically on unilateral PA, adrenalectomy demonstrated greater LVMI reduction than MRAs. CONCLUSIONS: This meta-analysis suggests that both adrenalectomy and MRAs improve LV remodeling. Although adrenalectomy was generally associated with slightly greater LVMI reductions than MRAs, the impact of optimized MRA therapy on LVMI reduction remains uncertain. When focusing specifically on patients with unilateral PA, adrenalectomy was associated with more pronounced regression of LV remodeling compared with MRA therapy.