Aldosterone antagonists in the treatment of hypertension

Aldosterone plays an important role in the pathogenesis and progression of a number of major cardiovascular diseases, including hypertension. It is believed, that aldosterone is involved in drug-resistant hypertension. Primary aldosteronism is one of the most common causes of resistant hypertension and affects about 8% of hypertensive patients, as published before. It therefore seems clear that in many cases aldosterone is the primary objective of effective control of blood pressure and aldosterone antagonists are highly valuable group of antihypertensive drugs. Many clinical trials indicated that these drugs are effective in monotherapy and provide significant additional blood pressure reduction when added to treatment of patients with resistant hypertension, including primary hyperaldosteronism. They appear to be effective in lowering BP regardless of the active renin level and plasma aldosterone concentration before treatment. They reduce also left ventricular hypertrophy in hypertensive patients. Spironolactone has been approved for a few decades in the treatment of essential hypertension. The widespread use of spironolactone in hypertension has been limited by the incidence of side effects, in particular gynecomastia, breast pain and impotence, which are dose-dependent antiandrogen actions. These listed adverse effects of spironolactone have been minimized by introduction of eplerenone, which is considerably more selective to mineralocorticoid receptor. Involvement of renin-independent mechanism has been suggested in the adrenal stimulation of aldosterone secretion in obese patients. There may be a subset of patients with visceral obesity and metabolic syndrome in whom the aldosterone antagonists might be of particular benefit, but this issue requires convincing data from clinical trials.