Changes in vascular structure and function in primary hyperparathyroidism: a systematic review and meta-analysis

Cardiovascular (CV) diseases, particularly ischemic heart disease and stroke, remain the leading cause of mortality worldwide and constitute a major global health challenge. Primary hyperparathyroidism (PHPT), a prevalent endocrine disorder, has recently emerged as a potential contributor to CV risk, although its impact on vascular structure and function has yet to be fully elucidated.

This systematic review and meta-analysis aimed to provide an in-depth characterization of vascular involvement by assessing markers of vascular remodeling and function in PHPT, including carotid intima-media thickness (IMT), carotid plaque prevalence, brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation (NMD), as well as the effects of parathyroidectomy (PTX) on these parameters.

A comprehensive literature search was conducted across four databases (PubMed, Embase, Web of Science and Scopus) until March 2026. Original studies written in English enrolling patients with PHPT and assessing the pre-specified vascular markers using ultrasound evaluation were included. Thirty-two studies were eligible for the qualitative synthesis, of which thirty were included in the meta-analysis.

Compared with controls, PHPT patients exhibited significantly increased carotid IMT and markedly reduced FMD, indicating early structural arterial changes and endothelial dysfunction. No significant differences were observed in carotid plaque prevalence or in NMD, the latter suggesting preserved endothelium-independent vascular function. PTX was associated with a modest short-term reduction in carotid IMT at 6 months, while improvements in endothelial function were inconsistent and did not reach statistical significance.

Overall, these findings support a model in which PHPT primarily affects vascular function through endothelial impairment, followed by mild structural remodeling, rather than advanced atherosclerotic plaque formation. These alterations may represent an early and potentially reversible stage of vascular disease. Although current guidelines do not include CV involvement as an indication for surgery, vascular markers may contribute to improved risk stratification and management decisions in PHPT. Further prospective studies employing standardized vascular assessment methodologies are needed to clarify the clinical significance of these findings.