Evolution of mineralocorticoid receptor antagonists, aldosterone synthase inhibitors, and alternative treatments for managing primary aldosteronism

Primary aldosteronism (PA) is a prevalent and curable secondary hypertensive disorder that accounts for 5–13% of all hypertension cases. The prevalence of resistant hypertension, cerebral and cardiovascular diseases, and renal complications is higher in PA patients than in those with essential hypertension. Appropriate diagnosis and treatment at an early stage may suppress cerebral and cardiovascular events. Lifestyle modifications recommended for essential hypertensive patients, including dietary salt restriction and appropriate calorie intake to avoid fat accumulation, play a crucial role in suppressing overactivation of the mineralocorticoid receptor (MR), which helps to control blood pressure and prevent end-organ damage. Esaxerenone is a safe mineralocorticoid receptor antagonist (MRA) with strong antihypertensive and anti-albuminuric effects. Aldosterone synthase inhibitors (ASIs) have been developed, which are antihypertensive agents with a new mechanism of action. The pharmacological mechanisms of MRAs and ASIs differ; MRAs block MR activity by preventing aldosterone and/or cortisol from binding to the MR, while ASIs block aldosterone secretion from the adrenal gland. Other new treatments, such as robot-assisted laparoscopic adrenalectomy, percutaneous computed tomography radiofrequency ablation, transvenous radiofrequency catheter ablation, and super-selective adrenal arterial embolization have been developed. Further research will lead to better treatments for PA patients and reduce the frequency of cerebral and cardiovascular events.