In this recent Medscape InDiscussion podcast Dr. Marwah Abdalla welcomes PWN’s Dr. Lewis Blevins to talk about secondary hypertension. This episode focuses on Cushing syndrome, an often overlooked cause of secondary hypertension. We’ll discuss why this condition is frequently missed, how clinicians can screen for cortisol excess in patients with hypertension, and what to consider when managing blood pressure in those found to have hypercortisolism.
Click here to listen to the podcast
Here’s a summary of their discussion:
Why is this diagnosis often missed:
- Rare disease that clinicians don’t think about frequently in busy practices
- Only 20-30% of patients have classic “cushingoid” appearance
- Many patients have mild disease that doesn’t present with typical physical features
- Adrenal adenomas often cause very mild hypercortisolism without obvious signs
Nomenclature and terminology confusion:
- Multiple overlapping terms: Cushing syndrome, hypercortisolism, MACS (mild autonomous cortisol secretion), hidden hypercortisolism
- Dr. Blevins prefers “pathologic cortisol secretion” and reserves “Cushing syndrome” for classic presentations
- Many patients have “relative hypercortisolism” – producing more cortisol than their individual body needs, even if lab values appear normal
When to Screen:
- Don’t assume only resistant/multidrug hypertension patients – many have run-of-the-mill hypertension on 1-2 medications
- Look for additional clues: weight gain, insomnia, osteoporosis, uncontrolled diabetes, easy bruising
- Low renin AND low aldosterone together suggest hypercortisolism (syndrome of apparent mineralocorticoid excess)
- 20-50% of adrenal incidentalomas have mild autonomous cortisol secretion
The diagnostic journey and approach:
- Screening tests: overnight 1mg dexamethasone suppression, late-night salivary cortisol, or 24-hour urine cortisol
- Normal 24-hour urine doesn’t exclude diagnosis – patient may still have relative hypercortisolism
- Refer complex cases to experienced endocrinologists, especially suspected pseudo-Cushing’s
Blood Pressure Management:
- Aldosterone receptor blockers (spironolactone, eplerenone) work best
- Alpha blockers, calcium channel blockers, and beta blockers don’t work as well
- Definitive treatment requires addressing underlying cause (surgery or medical therapy)
- Most patients see hypertension resolve after treatment, though some need continued medication
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