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Hypertension and Cushing's syndrome: hunt for the red flag
De Martino M C1, L Canu2, I Bonaventura3
1Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli Federico II, Naples, Italy.
Insights
Identifying Cushing's syndrome in hypertensive patients is crucial. Younger patients (<40 years), those with adrenal lesions, or rapidly evolving hypertension should be screened for this condition.
Area of Science:
- Endocrinology
- Hypertension Research
- Clinical Diagnostics
Background:
- Secondary hypertension affects 5-15% of hypertensive individuals.
- Cushing's syndrome (CS) is a rare but serious cause of hypertension, increasing cardiovascular risks.
- Identifying patients who need screening for endogenous hypercortisolism is a clinical challenge.
Purpose of the Study:
- To review the prevalence of Cushing's syndrome in hypertensive patients.
- To identify clinical phenotypes of hypertensive patients most likely to have Cushing's syndrome.
Main Methods:
- Systematic review adhering to PRISMA guidelines.
- Searched English-language studies updated to June 2023.
- Included eight studies analyzing prevalence data and screening methods for CS in hypertensive populations.
Main Results:
- Eight studies (1977-2020) included 11,504 patients.
- Overall CS prevalence ranged from 0-7.7%, with Cushing's disease (CD) at 0-1.2%.
- Highest prevalence observed in hypertensive patients <40 years (6.2%) and those with adrenal lesions (7.7%).
- The 1 mg overnight dexamethasone suppression test (1 mg DST) was the most common screening test.
Conclusions:
- A key CS profile includes younger age (<40), rapidly evolving hypertension, and adrenal adenomas.
- Patients with pituitary lesions should be prioritized for diagnostic workup.
- Screening tests (UFC, 1 mg DST, LNSC) are recommended for suspected CS; LNSC is often most discriminatory.
- For hypertensive patients with adrenal incidentalomas, 1 mg DST is recommended to rule out CS.
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.
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