ENDOCRINE CONSULT / PEER REVIEWED

Screening for Endocrine Hypertension

Clinician Reviews. 2019 June;29(6):5e-7e

References

1. Smith MA, Schrager S, WinklerPrins V. Essentials of Family Medicine. 7th ed. Baltimore, MD: Lipincott Williams & Wilkins; 2019.
2. US Preventive Services Task Force. High blood pressure in adults: screening [final recommendation statement]. www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/high-blood-pressure-in-adults-screening. Accessed May 20, 2019.
3. Puar T, Mok Y, Debajyoti R, et al. Secondary hypertension in adults. Singapore Med J. 2016;57:228-232.
4. Poulter NR, Prabhakaran D, Caulfield M. Hypertension. Lancet. 2015;386:801-812.
5. Faselis C, Doumas M, Papademetriou V. Common secondary causes of resistant hypertension and rational for treatment. Int J Hypertens. 2010;2011: doi: 10.4061/2011/236239.
6. Else T, Hammer GD. Disorders of the Adrenal Cortex. In: Hammer GD, McPhee SJ, eds. Pathophysiology of Disease: An Introduction to Clinical Medicine. 8th ed. New York, NY: McGraw-Hill; 2014.
7. Nieman L, Swearingen B; the Pituitary Society. Cushing’s syndrome and Cushing’s disease: your questions answered. www.pituitarysociety.org/sites/all/pdfs/Pituitary_Society_Cushings_brochure.pdf. Accessed May 20, 2019.
8. Koch, C. Chrousos, G. Overview of endocrine hypertension. In: Feingold KR, Anawalt B, Boyce A, et al, eds. Endotext. South Dartmouth, MA: MDText.com; 2016.
9. Barlow M, Abdel-Latif A. The forgotten cause of hypertension: a case report and literature review of the prevalence, diagnosis and management of primary aldosteronism. Case Rep Intern Med. 2018;5:4-7.
10. Viera A, Neutze D. Diagnosis of secondary hypertension: an age-based approach. Am Fam Physician. 2010;82:1471-1478.
11. Young WF, Calhoun DA, Lenders JWM, et al. Screening for endocrine hypertension: an Endocrine Society scientific statement. Endocr Rev. 2017;38:103-122.
12. Kotchen TA. Hypertensive vascular disease. In: Jameson JL, Fauci AS, Kasper DL, et al, eds. Harrison’s Principles of Internal Medicine. 20th ed. New York, NY: McGraw-Hill Education; 2018.
13. Rossi GP, Bernini G, Caliumi C, et al; PAPY Study Investigators. A prospective study of the prevalence of primary aldosteronism in 1,125 hypertensive patients. J Am Coll Cardiol. 2006;48:2293-2300.
14. Funder JW, Carey RM, Mantero F, et al. The management of primary aldosteronism: case detection, diagnosis, and treatment: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2016;101:1889-1916.
15. Stowasser M, Taylor PJ, Pimenta E, et al. Laboratory investigation of primary aldosteronism. Clin Biochem Rev. 2010;31:39-56.
16. Stowasser M, Gordon RD. The aldosterone-renin ratio for screening for primary aldosteronism. Endocrinologist. 2004;14:267-276.
17. Newell-Price J, Bertagna X, Grossman AB, et al. Cushing’s syndrome. Lancet. 2006;367:1605-1617.
18. Nieman LK, Biller BM, Findling JW, et al. The diagnosis of Cushing’s syndrome: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2008;93: 1526-1540.
19. Rimoldi S, Scherrer U, Messerli F. Secondary arterial hypertension: when, who, and how to screen? Eur Heart J. 2014;35:1245-1254.
20. Kirk L, Hash R, Harold K. Cushing’s syndrome and Cushing’s disease. Am Fam Physician. 2000;62:1133-1134.
21. Thomas RM, Ruel E, Shantavasinkul PC. Endocrine hypertension: an overview on the current etiopathogenesis and management options. World J Hypertens. 2015;5:14-27.
22. Ariton M, Juan CS, AvRuskin TW. Pheochromocytoma: clinical observations from a Brooklyn tertiary hospital. Endocr Pract. 2000;6:249-252.
23. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and treatment: a scientific statement from the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research. Hypertension. 2008;51(6):1403-1419.
24. Lenders JW, Eisenhofer G, Mannelli M, et al. Pheochromocytoma. Lancet. 2005;366:665-675.
25. Fishbein L, Else T. Disorders of the adrenal medulla. In: Hammer GD, McPhee SJ, eds. Pathophysiology of Disease: An Introduction to Clinical Medicine. 8th ed. New York, NY: McGraw-Hill; 2014.

PHEOCHROMOCYTOMA

Pheochromocytoma is a condition in which there is secretion of excess catecholamines, epinephrine, norepinephrine, and dopamine due to a tumor of the adrenal medulla.²¹ This is a rare disease and accounts for only 0.2% to 0.6% of all causes of hypertension.²² Hypertension (persistent or paroxysmal) is the most common finding for patients with pheochromocytoma, with 80% to 90% presenting with this finding.²³ It is important to note that approximately 10% of these patients will be normotensive. Three of the condition’s classic symptoms are headache, sweating, and palpitations.²⁴ Additional symptoms include anxiety, sense of impending doom, fever, nausea, or vomiting.²¹

If left untreated, there is risk for hypertensive retinopathy, nephropathy, myocardial infarction, stroke from cerebral infarction, intracranial hemorrhage, or embolism.²⁵ Due to the high rate of morbidity and mortality with untreated pheochromocytoma, laboratory testing should be initiated immediately upon suspicion of this diagnosis or if the patient has relevant family history.¹¹

Patients should be screened for pheochromocytoma if they have ≥ 1 of the following factors:

Resistant hypertension and hyperadrenergic symptoms (palpitations, perspiration, pallor, or headache)
Family history of pheochromocytoma
Any genetic syndrome with a known association to pheochromocytoma
An adrenal mass that is > 4 cm, is cystic, or has hemorrhagic changes.¹⁹

Pheochromocytoma is diagnosed by identifying high concentrations of plasma-free metanephrines or 24-hour fractionated metanephrines and catecholamines. Some medications can interfere with the accuracy of lab results and therefore may need to be temporarily stopped; it is important to check the specific lab guidelines and review the patient’s medication lists before tests are ordered and conducted.²⁵

ALWAYS SCREEN THE PATIENT

Although the causes of endocrine-related hypertension are very rare, screening for endocrine hypertension in patients who present with signs and symptoms of these conditions can greatly improve their lives. The endocrine disorders discussed in this article can be treated or controlled with appropriate diagnosis and treatment. In addition, resolving uncontrolled hypertension by addressing endocrine disorders can reduce the risk for long-term sequelae. It is important for clinicians to consider referral to an endocrine specialist if a patient has endocrine-related hypertension. In particular, patients with pheochromocytoma require quick referral due to a risk for high morbidity and mortality if left untreated.¹¹

Screening for Endocrine Hypertension

References

PHEOCHROMOCYTOMA

ALWAYS SCREEN THE PATIENT

Pages

Recommended Reading