Some hypertensive patients treated with an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) will develop aldosterone "breakthrough" (aka "escape").


Features of aldosterone breakthrough:

(1) history of long-term treatment with ACE inhibitor or ARB

(2) elevation in the plasma aldosterone concentration during therapy to a level above pre-treatment levels (others use a level above the upper limit of the normal reference range)

(3) physiologic consequences of an elevated aldosterone level (sodium retention, left ventricular hypertrophy, potassium loss, magnesium loss, refractory heart failure, a decline in GFR, etc.)


A patient showing aldosterone breakthrough and having stable potassium and salt balance may benefit from the addition of an aldosterone antagonist or renin inhibitor (Bomback and Klemmer).


Spironolactone antagonizes aldosterone and can improve diuresis and symptoms in patients with CHF who experience aldosterone breakthrough (Pitt).


According to Cicoira et al, this may be related to ACE gene polymorphism, affecting patients with the DD genotype.


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