Remission of hypertension after surgical cure of Cushing's syndrome

Hypertension and Cushing's syndrome: hunt for the red flag

INTRODUCTION

The prevalence of secondary hypertension is reported to be 5-15% of people with hypertension. Causes of secondary hypertension include Cushing's syndrome (CS), a rare but serious clinical condition characterized by chronic endogenous hypercortisolism associated with increased morbidity and mortality, especially for cardiovascular complications. The challenge for the clinician is thus to identify the phenotype of hypertensive patients who should be screened for endogenous hypercortisolism.

METHODS

This study was performed according to the PRISMA statement. The search was last updated in June 2023, and only English language studies were considered. Titles and abstracts have been screened for articles selection, identifying only those that dealt with prevalence of Cushing's syndrome in hypertensive patients. Finally, eight papers were included in the review. Data regarding year of publication, populations' characteristics, inclusion criteria, screening test and cut-off used, and CS prevalence have been extracted.

RESULTS

The study search identified eight studies, from 1977 to 2020, including a total number of 11,504 patients, ranging from 80 to 4429 patients for each study. The prevalence of CS reported was variable among the studies, ranging from 0 to 7.7%, having Cushing's disease (CD) a prevalence range of 0-1.2%. The highest prevalence has been found in selected populations of hypertensive patients younger than 40 years (6.2%) or harbouring an adrenal lesion (7.7%). The most used screening test was 1 mg overnight dexamethasone suppression test (1 mg DST), with different cut-off.

CONCLUSION

The most fitting CS profile encompasses younger age (i.e., < 40 years old), rapidly evolving hypertension and the presence of adrenal adenomas, along with subjects with pituitary lesions, who should still be prioritized in the diagnostic pathway. Overall, in the case of hypertensive patients presenting a clinical picture highly suggestive of CS, it is advisable to perform one of the available screening tests (UFC, 1 mg DST, LNSC). LNSC is likely the most discriminatory test and may be preferred, depending on its availability. Conversely, for hypertensive patients with an adrenal incidentaloma, the 1 mg DST is recommended as the screening test to exclude CS.

Diagnosis and management of hypertension in patients with Cushing's syndrome: a position statement and consensus of the Working Group on Endocrine Hypertension of the European Society of Hypertension

Endogenous/exogenous Cushing's syndrome is characterized by a cluster of systemic manifestations of hypercortisolism, which cause increased cardiovascular risk. Its biological basis is glucocorticoid excess, acting on various pathogenic processes inducing cardiovascular damage. Hypertension is a common feature in Cushing's syndrome and may persist after normalizing hormone excess and discontinuing steroid therapy. In endogenous Cushing's syndrome, the earlier the diagnosis the sooner management can be employed to offset the deleterious effects of excess cortisol. Such management includes combined treatments directed against the underlying cause and tailored antihypertensive drugs aimed at controlling the consequences of glucocorticoid excess. Experts on endocrine hypertension and members of the Working Group on Endocrine Hypertension of the European Society of Hypertension (ESH) prepared this Consensus document, which summarizes the current knowledge in epidemiology, genetics, diagnosis, and treatment of hypertension in Cushing's syndrome.

Endocrine hypertension secondary to adrenal tumors: clinical course and predictive factors of clinical remission

PURPOSE

Endocrinopathies constitute ~ 10% of secondary hypertension (SH) etiologies. Primary aldosteronism, pheochromocytoma (PHEO), and Cushing's syndrome are common causes. Early identification and treatment result in resolution/improvement of SH. The aim of this study was to characterize the clinical course, outcomes, and remission-associated prognostic factors of SH related to adrenal tumors.

METHODS

Retrospective cohort study including patients with SH who underwent adrenalectomy from 2000 to 2019. Postoperative outcomes were analyzed. Remission was defined as normalization of blood pressure without drug use.

RESULTS

Eighty-three patients with SH were included. Mean ± SD age was 38.8 ± 14.2 years and 75.9% were women. Diagnosis was PHEO in 35 patients (42.2%), aldosteronoma (APA) in 28 (33.7%), cortisol producing adenoma (CPA) in 16 (19.3%), and ACTH-dependent Cushing's in 4 (4.8%). Laparoscopic adrenalectomy was performed in 81 (97.6%) patients. Mean ± SD follow-up was 57.4 ± 49.6 months (range 1-232). Surgical morbidity occurred in 7.2% of patients and there was no mortality. Remission of SH occurred in 61(73.5%): 100% of ACTH-dependent Cushing's, 85.7% of PHEO, 68.8% of CPA, and 57.1% of APA. Biochemical phenotype and the combination of larger tumor size, number of antihypertensive drugs, male gender, older age, obesity, and preoperative SH for more than 5 years were associated with less likely clinical remission in patients with APA (p = 0.004), CPA (p < 0.0001), and PHEO (p < 0.0001).

CONCLUSION

SH remission rates are 57-100% after adrenalectomy. Several prognostic factors could be used to predict SH control. Adrenalectomy provides good clinical outcome and must be considered a treatment option in all surgical candidates.