What is the typical blood pressure presentation in adrenal insufficiency?

Blood Pressure in Adrenal Insufficiency

Patients with adrenal insufficiency typically present with hypotension, which progresses from orthostatic hypotension to supine hypotension and ultimately shock if untreated. 1, 2

Characteristic Blood Pressure Patterns

Chronic Adrenal Insufficiency

• Orthostatic (postural) hypotension is an early and cardinal feature, occurring before supine hypotension develops 1
• Patients demonstrate lower nocturnal systolic and diastolic blood pressure compared to healthy individuals (108 vs. 117 mmHg systolic; 65 vs. 73 mmHg diastolic) 3
• Chronic hypotension is present even at rest, though there is no specific threshold defining hypotension—symptoms typically occur when systolic pressure falls below 90 mmHg and diastolic below 60 mmHg 4
• Cardiovascular features consistent with hypovolemia are present, including smaller left ventricular and left atrial dimensions 3

Acute Adrenal Crisis

• Volume-resistant hypotension progresses to frank shock if not rapidly corrected 1, 2
• The pathophysiology involves progressive loss of vasomotor tone and impaired alpha-adrenergic receptor responses to noradrenaline due to insufficient cortisol production 1
• Severe hypotension and shock are common manifestations requiring immediate intervention 2, 5
• Dehydration and volume depletion are key pathophysiologic features driving the hypotension 2, 5

Clinical Monitoring Approach

Monitor both sitting (or standing) and supine blood pressure for early detection of orthostatic hypotension, as this represents an earlier warning sign than supine hypotension alone 1. The orthostatic component may be the only blood pressure abnormality in early or well-compensated adrenal insufficiency.

Key Clinical Pitfalls

• Do not wait for supine hypotension to develop—orthostatic changes occur first and represent a critical early warning sign 1
• Volume-resistant hypotension may be a late or even agonal event in adrenal crisis, so earlier symptoms (malaise, somnolence, cognitive dysfunction) should trigger intervention 1, 2
• The absence of hypotension does not exclude adrenal insufficiency, particularly in chronic cases with adequate salt intake and mineralocorticoid replacement 1

Underlying Mechanisms

The hypotension in adrenal insufficiency results from multiple factors:

• Mineralocorticoid deficiency (in primary adrenal insufficiency) causes sodium loss in urine, leading to volume depletion 1
• Glucocorticoid deficiency impairs vasomotor tone and alpha-adrenergic receptor responsiveness 1
• Increased plasma vasopressin and angiotensin II impair free water clearance, contributing to hyponatremia and further volume dysregulation 1
• The combination creates a state of chronic hypovolemia with cardiovascular structural changes 3

Treatment Implications

When hypotension is present in suspected adrenal insufficiency, immediate treatment with hydrocortisone 100 mg IV and aggressive fluid resuscitation with 0.9% saline at 1 liter over the first hour is required 2, 5, 6. This high dose of hydrocortisone provides both glucocorticoid and mineralocorticoid effects by saturating 11β-hydroxysteroid dehydrogenase type 2 2, 6. Treatment should never be delayed for diagnostic confirmation when clinical suspicion exists 1, 2, 5.