Adrenal Tumors and High Blood Pressure
High blood pressure is a silent killer. High blood pressure is also known as hypertension. It is one of the most common diseases in the world and most people believe you cannot be cured of high blood pressure. They believe that the only option is to treat it with blood pressure medications. Doctors and patients try one pill after another to get the blood pressure down. Although that works for some patients, there is a huge number of patients with adrenal tumors who can actually be cured from their hypertension.
The importance of diagnosing and treating high blood pressure is that it is a major risk factor for stroke, heart disease, kidney disease and heart arrhythmias. When your blood pressure is too high, it causes damage to all cells in the body. The inner lining of all your blood vessels (endothelium) is especially affected and that leads to end organ damage of the brain, heart, kidneys, and other tissues. Hypertension is a terrible disease and kills patients over months, years, and decades. It is also a silent killer because if you do not measure your blood pressure you may not know that you have hypertension
Adrenal Tumors and High Blood Pressure
The good news is that if you have an adrenal tumor and high blood pressure, you can actually cure the hypertension by removing the adrenal tumor. If you have high blood pressure, make sure that you do not have an adrenal tumor. You do not want to just treat your high blood pressure with one pill after another when the underlying problem is an adrenal tumor that can easily be fixed.
Treating high blood pressure from an adrenal tumor with pills instead of surgery is like treating a major bleeding artery with a Band-Aid. If your doctor is doing this, he or she is just treating the symptom not the root cause.
If you have hypertension and have not been investigated for adrenal tumors, please print this blog post, and bring it to your primary care doctor for your next visit. Patients with high blood pressure need to have tests to make sure there is not an underlying adrenal tumor.
Table. High blood pressure categories. Patients with hypertension need to be screened for an adrenal tumor.
High Blood Pressure and Primary Hyperaldosteronism
Primary Hyperaldosteronism (also known as Conn’s syndrome) is due to an aldosterone producing tumor of the adrenal gland. Too much aldosterone is very toxic for the body and leads to high blood pressure.
Too much aldosterone causes hypertension through a variety of mechanisms. The excess aldosterone induces potassium secretion, meaning that we lose the potassium through the kidneys (urine) and at the same time retain sodium. The high sodium in the blood stream means that the heart has to work harder, what is called increased cardiac output. Aldosterone also directly works on the vessels inner lining called endothelium and constrict those vessels. The high aldosterone levels not only lead to high blood pressure but target organ damage to the brain, heart, kidneys, and blood vessels.
The high blood pressure of primary hyperaldosteronism often is mild initially but then especially the diastolic (lower) pressure starts rising. Unfortunately, patients have often have had hypertension for years before getting screened for an aldosterone-producing tumor.
The damage to the blood vessels and kidneys by aldosterone in itself worsens the high blood pressure even more over time. It is not uncommon that patients with primary hyperaldosteronism need to be treated with 3-5 blood pressure medications.
If you have high blood pressure, do not wait until your brain, heart, kidneys, and blood vessels are damaged before you make sure you do not have an adrenal tumor.
After successful adrenal surgery, the blood pressure gradually normalizes over the next several weeks and months. If the patient has had significant end organ damage to the heart, blood vessels and the kidneys due to delay in diagnosis and/or severe stage disease, the blood pressure will get better but not always normalize.
Learn more about primary hyperaldosteronism and Conn’s syndrome symptoms, diagnosis, and treatment.
High Blood Pressure and Pheochromocytoma
The manifestations of pheochromocytoma represent periods of sudden release of the adrenaline-like hormones from the tumor, known as catecholamines.
A typical spell would begin with generalized pounding, headache, palpitations, tachycardia, sweating, tremors, anxiety and feeling of impending doom. If you measure the blood pressure during one of these spells it will be very high.
It is important to understand that not all patients with pheochromocytoma have persistently high blood pressure. This means that if your doctor measures your blood pressure when you do not have a spell, it may be normal. We even had patients who were frankly told it was impossible that they had pheochromocytoma because the baseline blood pressure was completely normal. This is a misunderstanding. About 10% have no hypertension at all, and do not have the classical spells. About half of all patients have hypertension that is “sustained”; meaning they have high blood pressure at all times. The remainder have normal blood pressure in between attacks, and the blood pressure only goes up during an attack.
The epinephrine and norepinephrine (adrenaline-type hormones) cause vessel constriction which leads to hypertension. Both hormones also stimulate receptors in the heart with leads to an increase heart rate. Sustained and episodic release of the catecholamines leads to damage of the heart, brain, kidneys, and blood vessels which all in turn leads to a negative spiral with higher and higher blood pressure.
Remarkably, the hypertension is often cured right before our eyes in the operating room once the pheochromocytoma is removed. It is amazing how quickly patients’ blood pressure normalizes after surgery for pheochromocytoma (often performed in about 20 minutes), and many patients walk out the hospital the next morning free from any blood pressure pills. They have a spring in their step after having struggled, sometimes for decades, with multiple strong hypertension medications.
Similar to Conn’s syndrome, the longer a pheochromocytoma has gone untreated, the more organ damage to the blood vessels, heart, and kidneys, and thus the patient may still have problems with “essential” hypertension.
Learn more about pheochromocytoma symptoms, diagnosis, and treatment.
High Blood Pressure and Cushing’s syndrome
Cushing’s and subclinical Cushing’s syndromes can be caused by cortisol over-production from an adrenal tumor. Subclinical Cushing’s (less severe than overt disease) is more common.
Too much cortisol leads to hypertension in up to 95% of adult’s patients. Cortisol has many functions on many cells of the body and the high blood pressure is due to an imbalance of factors involving vessel dilatation and vessel constriction. Similar to aldosterone, cortisol leads to increased sodium and water retention, increased peripheral resistance and up regulation of the renin-angiotensin (hormonal system controlling the blood pressure) system activity.
Too much cortisol also leads to weight gain. Obesity causes increased peripheral resistance and sympathetic drive (meaning the heart and vessels will have to work too hard). This leads to a vicious cycle of worsening hypertension.
After successful adrenal surgery, the blood pressure gradually normalizes over the next several weeks and months. Due to other risk factors and end organ damage to the heart, blood vessels and the kidneys, 30% of patients with Cushing’s syndrome still have problem with hypertension after curative adrenal surgery.
Learn more about Cushing’s syndrome symptoms, diagnosis, and treatment.
Who should be tested for an adrenal tumor as a cause of high blood pressure?
The short answer is everyone! However, if you belong to any of the below groups, the likelihood that you have an adrenal tumor is even higher.
- Resistant hypertension (i.e. poor response to medications)
- Hypertension requiring two or more blood pressure medications
- Hypertension requiring being on Spironolactone (Aldactone), Eplerenone (Inspra) or Amiloride
- Hypertension of any grade, without known risk factors such as age, smoking. kidney problems, diabetes, obesity, etc
- Hypertension at a young age (< 50 years of age)
- Hypertension with low blood potassium (hypokalemia) (this is classic for Conn's Syndrome).
- Hypertension with an adrenal incidentaloma (adrenal tumor found when x-raying for something else)
- Hypertension and sleep apnea
- Hypertension and a family history of early-onset (< 50 years of age) hypertension or stroke at a young age
- Hypertension in a family with any family member with an adrenal tumor (whether a Conn's Syndrome tumor, Cushing’s Syndrome, or pheochromocytoma/paraganglioma)
- Hypertension that is episodic - it comes and goes (paroxysmal; spells)
High blood pressure in patients with thyroid and parathyroid problems
Important to know! There are other causes of secondary hypertension not related to the adrenal gland. One such disease is primary hyperparathyroidism, due to one or more parathyroid tumors. Endocrine hypertension can also be caused by diseases of the thyroid gland.
Learn about high blood pressure and parathyroid disease and hyperparathyroidism.
Changes in your blood pressure can also be related to thyroid disease.
Read about thyroid disease, hyperthyroidism, and thyroid surgery.
Additional Resources:
Learn more about the Carling Adrenal Center
Learn more about Dr. Tobias Carling
Learn more about our sister surgeons at the Norman Parathyroid Center, Clayman Thyroid Center and Scarless Thyroid Surgery Center