With William F. Young, Jr, and Tamara Wexler, MD, PhD
Since hypertension (HTN) is the presenting symptoms for a myriad of endocrine-related disorders, the Endocrine Society calls on endocrinologists to take a more aggressive approach to screening their at-risk patients.1
At least 15 hormone-related conditions may lead to high blood pressure.1 However, clinicians do not always test patients for these conditions, delaying treatment and increasing their risk for complications of hypertension, including potentially life-threatening cardiovascular and kidney disease, according to a new scientific statement on screening for endocrine HTN, published in Endocrine Reviews.
“An accurate diagnosis of endocrine HTN provides clinicians with the opportunity to render a surgical cure or to achieve an optimal clinical response with specific pharmacologic therapy,” the authors said. Admittedly, “it is challenging for the clinician to know when and how to perform case-detection testing for all the endocrine disorders in which hypertension may be the presenting symptom," they said.
Among the more prevalent endocrine conditions linked to HTN are:
· Primary aldosteronism (5% and 10% of HTN cases, including sleep apnea)
· Secondary aldosteronism (ie, renovascular HTN)
· Thyroid disease (both hyper- and hypothyroidism)
· Cushing syndrome
· Hypercalcemia (ie, hyperparathyroid disease)
· Neuroendocrine chromaffin-cell tumors (ie, adrenergic and noradrenergic tumors)
· Obstructive sleep apnea (affects ~20% of adults; strongly associated with resistant HTN)
Many of the conditions the scientific statement cites are rare—for example, acromegaly, primary cortisol resistance, neuroendocrine tumors and tumors that affect the adrenal glands. The incidence of such conditions can be higher in certain populations of patients, particularly children and young adults. In children, 50% of cases arise as secondary HTN, and in young adults (under 40 years of age), 30% of cases are caused by secondary HTN.
Specific screening recommendations are outlined for each of the endocrine conditions.1
Subclinical primary aldosteronism may lead to mild elevations in blood pressure. Between 30% and 40% of patients with hypertension express low plasma levels of renin, which may reflect subclinical primary aldosteronism,2 according to the AACE Adrenal Scientific Committee.
“Multiple intervention studies for severe or resistant HTN in populations with a low renin have shown that [mineralocorticoid-receptor] antagonists are equivalent or superior to alternatives such as angiotensin receptor blockers, angiotensin converting enzymes inhibitors, diuretics, and adrenergic antagonists,” the authors reported.
Clinical presentation should largely guide the decision of whether to test for an underlying endocrine disorder such as Cushing’s disease or hypothyroidism.1,2 In addition, “clinical context is important” when determining whether to screen patients for hormone-related causes of high blood pressure, according to the authors.
“Case detection for endocrine hypertension may not be clinically important in an older patient with multiple life-limiting comorbidities,” they wrote. “However, screening for endocrine hypertension may be key to enhancing and prolonging life in most patients with hypertension, especially younger patients.”
Although endocrinologists are aware of the conditions in the scientific statement, “what we have done in this manuscript is to provide this information in one place and hopefully we have provided it in an easily understood way,” William F. Young, Jr., lead author of hypertension screening recommendations,1 told EndocrineWeb.
“We focus on prevalence, clinical presentation, guidance on when to perform case-detection testing, and the currently available case detection tests,” said Dr. Young, who is chair of the Division of Endocrinology, Diabetes, Metabolism, and Nutrition, and the Tyson Family Endocrinology Clinical Professor at Mayo Clinic College of Medicine in Rochester, Minn.
Optimal management of endocrine-related hypertension will require better communication between primary care physicians and specialists, Dr. Young noted.
“Most cases of hypertension in the United States and around the world are managed by primary care providers,” he said. “If these providers are not thinking of the forms of endocrine HTN when evaluating and treating patients, endocrine-related high blood pressure goes undiagnosed and leads to excessive morbidity and mortality.”
“For example, an accurate diagnosis of primary aldosteronism provides clinicians with the opportunity to render a surgical cure or to achieve an optimal clinical response with specific pharmacologic therapy. Undiagnosed primary aldosteronism leads to renal failure requiring dialysis—an outcome that is totally preventable,” Dr. Young told EndocrineWeb.
The screening guidelines represent “only the start” of raising awareness, Dr. Young added. The authors stated that “clinical context is important.“ Screening for endocrine HTN is particularly important in cases in which treatment can be most beneficial in extending life, such as in younger patients.1
“We need to use every avenue of communication available to us. We need to ‘spread the word’ with presentations at meetings. We need to provide straightforward guides that can be used in the clinic—this is something that the Endocrine Society is currently working on. We need to emphasize the importance of case detection in web articles and interviews such as this one,” he told EndocrineWeb. “Another avenue we need to explore is a direct to patient awareness campaign. All individuals with hypertension should be asking their primary care provider if they have a reversible form of hypertension.”
Tamara Wexler, MD, PhD, former director of the NYU Langone Medical Center Pituitary Center in New York City, said the scientific statement1 reflects the growing understanding that endocrine causes of hypertension appear to be on the rise.
“For years, it was assumed that endocrine causes were responsible for between 1% and 3% of cases. Now there’s some evidence that they’ve become more common,” Dr. Wexler said. “We still don’t really know how common they are, but it’s important to think about because there are some clues and cues that there is an endocrine cause” of high blood pressure.“
Research also suggests that HTN that results from a hormonal trigger is more likely to produce cardiovascular disease than other forms of the condition, Dr. Wexler added. On the other hand, she noted, these patients may respond better to treatment because clinicians can address the root cause of high blood pressure directly.
In the case of tumors, for example, she said, “some patients are really good candidates for surgery and you essentially remove the problem.”
1. Young WF, Calhoun DA, Lenders JWM, Stowasser M, Textor SC. Screening for Endocrine Hypertension: An Endocrine Society Scientific Statement. Endocr Rev. 2017; 38(2):103-122.
2. Vaidya A, Malchoff CD, Auchus RJ, on behalf of the AACE Adrenal Scientific Committee. An Individualized Approach to the Evaluation and Management of Primary Aldosteronism. Endocr Pract. 2017. Published online ahead of print. Available at: http://journals.aace.com/doi/10.4158/EP161717.RA?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed&code=aace-site