From the Guidelines
Primary hyperaldosteronism, Cushing's syndrome, and other endocrine disorders are the primary causes of hypertension, with primary hyperaldosteronism being the most common form of secondary hypertension, as stated in the 2024 ESC guidelines 1.
Endocrine Disorders Causing Hypertension
Several endocrine disorders can cause elevated blood pressure, including:
- Primary hyperaldosteronism, which occurs when the adrenal glands produce too much aldosterone, causing sodium and water retention while increasing potassium excretion, leading to hypertension 1
- Cushing's syndrome, characterized by excess cortisol production, which causes hypertension through multiple mechanisms including increased sodium retention and enhanced vascular sensitivity to catecholamines 1
- Pheochromocytoma, a rare tumor of the adrenal medulla that secretes excess catecholamines, causing episodic or sustained hypertension with symptoms like headaches, sweating, and palpitations
- Thyroid disorders, which impact blood pressure - hyperthyroidism can cause systolic hypertension due to increased cardiac output, while hypothyroidism may lead to diastolic hypertension from increased peripheral resistance
- Acromegaly, caused by excess growth hormone, which leads to hypertension through sodium retention and increased cardiac output
- Hyperparathyroidism, which elevates blood pressure through increased calcium levels affecting vascular tone
- Congenital adrenal hyperplasia, which can cause hypertension in certain enzyme deficiencies
Treatment and Management
Treatment typically involves addressing the underlying endocrine disorder, often through medication or surgery, rather than just managing the hypertension symptomatically. For primary hyperaldosteronism, surgical removal of the offending adrenal gland is typically considered, unless the patient is older or has co-morbidities of concern, while medical treatment is based on mineralocorticoid receptor antagonists (MRAs) such as spironolactone or eplerenone 1.
Key Considerations
It is essential to note that the management of primary aldosteronism depends on its subtype, particularly on adrenal lesions being unilateral or bilateral, because the unilateral forms are amenable to surgical treatment while the latter require lifelong medical treatment 1. Additionally, the aldosterone:renin activity ratio is currently the most accurate and reliable means of screening for primary aldosteronism 1.
Recent Guidelines
The 2024 ESC guidelines for the management of elevated blood pressure and hypertension provide detailed information on the diagnosis, evaluation, and treatment of primary aldosteronism, including the use of MRAs and newer agents such as finerenone and exarenone 1. The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also provides recommendations for the screening and treatment of primary aldosteronism 1.
From the FDA Drug Label
- 2 Pharmacodynamics Aldosterone antagonist activity: Increased levels of the mineralocorticoid, aldosterone, are present in primary and secondary hyperaldosteronism.
The endocrine disorders that cause hypertension mentioned in the drug label are:
- Primary hyperaldosteronism
- Secondary hyperaldosteronism 2
From the Research
Endocrine Disorders Causing Hypertension
The following endocrine disorders can cause hypertension:
- Primary aldosteronism: the most common cause of endocrine hypertension, accounting for 1%-10% in uncomplicated hypertension and 7%-20% in resistant hypertension 3, 4, 5
- Congenital adrenal hyperplasia: a condition that can cause endocrine hypertension 3
- Liddle syndrome: a rare genetic disorder that can cause hypertension 3
- Pheochromocytomas: a type of tumor that can cause excess production of catecholamines, leading to hypertension 3, 4, 6
- Cushing's syndrome: a condition caused by excess production of glucocorticoids, which can lead to hypertension 3, 4, 5, 6
- Acromegaly: a condition caused by excess production of growth hormone, which can lead to hypertension 3
- Thyroid diseases: certain thyroid conditions, such as hyperthyroidism, can cause hypertension 3, 5, 7
- Primary hyperparathyroidism: a condition that can cause excess production of parathyroid hormone, leading to hypertension 3, 5
- Iatrogenic hormone manipulation: certain medications or treatments that affect hormone levels can cause hypertension 3
Diagnosis and Treatment
Early identification and treatment of the underlying endocrine disorder can help reduce morbidity and mortality related to hypertension 3, 4, 5. Diagnosis requires a high index of suspicion and the use of appropriate screening tests based on clinical presentation 5, 7. Imaging modalities, both functional and anatomic, may be used to locate the source of hormonal excess 6. Specialist units may be necessary to coordinate confirmatory tests and radiological procedures 7.