Multimodality Imaging in Aldosterone-Induced Cardiomyopathy: Early Detection and Prognostic Implications

Abstract

Primary aldosteronism (PA), the most common cause of secondary hypertension, is increasingly recognized as an independent driver of adverse cardiac remodeling, mediated through mechanisms beyond elevated blood pressure alone. Chronic aldosterone excess leads to myocardial fibrosis, left ventricular hypertrophy, and diastolic dysfunction via mineralocorticoid receptor activation, oxidative stress, inflammation, and extracellular matrix dysregulation. These changes culminate in a distinct cardiomyopathy phenotype, often underrecognized in early stages. Multimodality cardiac imaging, led primarily by conventional and speckle-tracking echocardiography, and complemented by exploratory cardiac magnetic resonance (CMR) techniques such as T1 mapping and late gadolinium enhancement, enables non-invasive assessment of structural, functional, and tissue-level changes in aldosterone-mediated myocardial damage. While numerous studies have established the diagnostic and prognostic relevance of imaging in PA, several gaps remain. Specifically, the relative sensitivity of different modalities in detecting subclinical myocardial changes, the long-term prognostic significance of imaging biomarkers, and the differential impact of adrenalectomy versus medical therapy on cardiac reverse remodeling require further clarification. Moreover, the lack of standardized imaging-based criteria for defining and monitoring PA-related cardiomyopathy hinders widespread clinical implementation. This narrative review aims to synthesize current knowledge on the pathophysiological mechanisms of aldosterone-induced cardiac remodeling, delineate the strengths and limitations of existing imaging modalities, and critically evaluate the comparative effects of surgical and pharmacologic interventions. Emphasis is placed on early detection strategies, identification of imaging biomarkers with prognostic utility, and integration of multimodal imaging into clinical decision-making pathways. By outlining current evidence and highlighting key unmet needs, this review provides a framework for future research aimed at advancing personalized care and improving cardiovascular outcomes in patients with PA.

Keywords: adrenalectomy; cardiac magnetic resonance; cardiac remodeling; echocardiography; left ventricular hypertrophy; mineralocorticoid receptor antagonists; primary aldosteronism.

Figure 1

Structural and Cellular Mechanisms of Aldosterone-Induced Cardiac Remodeling. This illustration demonstrates the complex pathological mechanisms by which aldosterone excess drives cardiac remodeling in primary aldosteronism. Key features include cardiomyocyte hypertrophy, apoptosis, interstitial and perivascular fibrosis, and microvascular remodeling. These changes are mediated through mineralocorticoid receptor activation and amplified by oxidative stress, inflammation, and dysregulated extracellular matrix turnover. Collectively, these alterations contribute to impaired myocardial relaxation, diastolic dysfunction, and adverse ventricular remodeling. Abbreviations: MR, mineralocorticoid receptor.

Figure 2

Timeline of Echocardiography Progress in Primary Aldosteronism. 1990s—M-mode and Doppler: Detection of LV hypertrophy, altered diastolic filling (E/A, DT, IVRT). 2000s—Tissue Doppler Imaging (TDI): Early diastolic mitral annular velocity (e′), filling pressure (E/e′). 2010s—Speckle-Tracking Echocardiography: Global longitudinal strain (GLS) for early systolic dysfunction. Myocardial Work: Afterload-independent assessment of myocardial performance. Today—Integrated Imaging: Comprehensive assessment of LV structure, systolic and diastolic function in PA. Abbreviations: DT, deceleration time; IVRT, isovolumic relaxation time; E/A ratio, early (E) to late (A) transmitral flow velocities; LV, left ventricle; S′, systolic annular velocity; e′, early diastolic mitral annular velocity; a′, late diastolic mitral annular velocity; GLS, global longitudinal strain; GWI, global work index; GCW, global constructive work; GWW, global wasted work; GWE, global work efficiency; ADX, adrenalectomy; MRAs, mineralocorticoid receptor antagonists.