Can an adrenal mass cause elevated blood pressure?

Can an Adrenal Mass Cause Elevated Blood Pressure?

Yes, adrenal masses are a well-established cause of secondary hypertension, and all patients with hypertension should be screened for primary aldosteronism, the most common endocrine cause of elevated blood pressure. 1

Mechanisms and Prevalence

Adrenal masses cause hypertension through three primary mechanisms:

• Primary aldosteronism (PA): The most common culprit, affecting 5-14% of hypertensive patients in primary care and up to 30% in referral centers 1. Excessive aldosterone production leads to sodium retention, volume expansion, and direct vascular effects that elevate blood pressure.

• Pheochromocytoma: Catecholamine-secreting tumors that cause severe, often paroxysmal hypertension with dramatic blood pressure fluctuations (systolic BP can vary between 30-300 mmHg) 2. These can present with life-threatening hypertensive crises mimicking acute coronary syndrome.

• Cortisol-secreting adenomas: Cause Cushing syndrome with sustained hypertension as part of the clinical picture 3, 4.

Screening Approach

For all patients with adrenal incidentalomas, systematic hormonal screening is mandatory 3:

1. Screen for autonomous cortisol secretion using 1 mg dexamethasone suppression test in all patients 3

2. Screen for primary aldosteronism with aldosterone-to-renin ratio (ARR) in patients with hypertension and/or hypokalemia 3. An ARR >1190 is highly suggestive 5.

3. Screen for pheochromocytoma with plasma or 24-hour urinary metanephrines if:

   • The mass shows >10 HU on non-contrast CT, OR
   • Signs/symptoms of catecholamine excess are present 3
   • Do not screen if unequivocal adenoma (<10 HU) without adrenergic symptoms 3

Critical Clinical Pitfalls

Even radiologically "benign" adrenal masses can be hormonally active. A case report demonstrated an aldosterone-producing microadenoma that was not detected on preoperative CT but caused resistant hypertension 4. Similarly, ectopic adrenal adenomas in unusual locations (e.g., between pancreas and adrenal gland) can be missed on standard imaging 5.

Adrenal cysts, typically considered benign, can occasionally cause hypertension through mass effect or hormonal activity 6. This underscores that size and imaging characteristics alone do not exclude functional significance.

Treatment Outcomes

Surgical resection of functional adrenal masses achieves excellent blood pressure control:

• Aldosterone-producing adenomas: Complete normalization of blood pressure without antihypertensive medications post-adrenalectomy 5, 4
• Pheochromocytomas: Resolution of hypertensive crises and blood pressure stabilization 2
• Cortisol-secreting adenomas: Improvement in metabolic comorbidities and blood pressure 3

Minimally invasive surgery should be performed when feasible for aldosterone-producing adenomas and pheochromocytomas 3. For primary aldosteronism, adrenal vein sampling is mandatory before offering surgery to confirm lateralization 3.

Key Cardiovascular Risks

Primary aldosteronism is not just about blood pressure elevation—it carries independent cardiovascular risks including stroke, atrial fibrillation, and renal injury beyond what would be expected from hypertension alone 1. This makes detection and specific treatment (mineralocorticoid receptor antagonists or surgery) particularly important for reducing long-term cardiovascular morbidity and mortality.

The multidisciplinary team (endocrinology, surgery, radiology) should be involved early when imaging suggests anything other than a simple benign lesion, when hormone hypersecretion is detected, or when surgery is considered 3.