Resolution of Hypertension with Surgical Remission of Cushing's Syndrome

Presentation Number: SAT 406
Date of Presentation: April 1st, 2017

Raven N. McGlotten*1 and Lynnette K. Nieman2
1NIDDK, NIH, 2NIH, Bethesda, MD

Abstract

Background: The Endocrine Society’s Guideline states that it is important to normalize co-morbidities of Cushing’s syndrome (CS) (1). Hypertension (HTN) is one of the most common comorbidities of CS, affecting about 80% of adult patients (pts) (2). While the pathophysiology of hypertension is multifactorial, its reversibility after successful surgical cure of CS is not well understood. We evaluated changes to blood pressure (BP) shortly after surgical remission and up to one year later.

Methods: We retrospectively studied all patients undergoing surgical treatment of CS under our protocols at the NIH Clinical Center from 12/2011 through 9/2016. Ectopic ACTH syndrome (EAS), Adrenal adenoma (AA) or Cushing ’s disease (CD) was diagnosed based on surgical pathology. Pts were considered to have HTN based on medical history, physical examination or if they were on oral antihypertensive agents (AHAs). After surgery pts remained inpatient for 7-15 days. Hydrocortisone (10-12mg/m2) was started when remission was confirmed, usually by post-operative day 4. Resolution of HTN was defined as systolic BP ≤120 mmHg and diastolic BP ≤80 mmHg off AHAs. BP values were compared between 1) the first morning after pre-operative inpatient admission from 0600-0800h, 2) the morning of discharge (DC), and 3) the morning of follow up (f/u) clinic visit(s).

Results: At baseline (BL) 30 (25 female) of 51 patients had a diagnosis of HTN and all received AHAs (25=CD, 4=EAS, 1-AA); each achieved remission. By DC, 12 were on no AHAs, 15 had a decrease in the number or dose of AHAs, and 2 had no change in AHAs. The median systolic value decreased from 130 to 125 mmHg with no change in diastolic values (p>0.05). Three pts had no further f/u.

Of 25 patients with 6 month f/u, 13 were taking no AHAs, 10 had a decrease in AHA number from BL, and 2 had no change to medications. Of note, one patient with no change was on an increased dose of hydrocortisone due to severe fatigue. There was a decrease in systolic (p=0.012, median 124 vs 130 mmHg) and diastolic (p=0.016, median 72 vs 75 mmHg) values from BL.

23 pts had 12 month f/u, including 2 who were not seen at 6 mo. Of these, 15 were on no AHAs; 5 had a decrease in medication number or dose. Of 3 pts with no change from BL, 2 were on a stable antihypertensive regimen from BL to 12 month f/u. One pt, who was on a decreased regimen at DC, restarted BL AHAs 3 months post-surgery due to rising BP. There was a decrease in systolic (p=0.0026, median 116 mmHg) and diastolic (p=0.0015, median 66 mmHg) values from BL. HTN fully resolved in 11 of the 23 pts.

Conclusion: While many factors affect BP, surgical remission of CS can lead to rapid improvement of HTN, requiring adjustment of antihypertensive agents as early as the first week after surgery. We recommend close monitoring of BP, especially in the first 15 days post operatively, patient education, and long term follow up for optimal treatment of hypertension in this population.

 

Nothing to Disclose: RNM, LKN