medwireNews: Patients with hypertension and mild autonomous cortisol secretion (MACS) due to unilateral adrenal incidentalomas are more likely to reduce antihypertensive treatment and reach normal blood pressure (BP) after minimally invasive adrenalectomy than with conservative management, research shows.
“Until now, the benefit of adrenalectomy for MACS due to unilateral adrenal incidentalomas remained uncertain,” write Antoine Tabarin (CHU Bordeaux, France) and co-authors in The Lancet Diabetes & Endocrinology.
This has meant that “the therapeutic attitude of treating physicians varied and guidelines were very cautious in their recommendations for surgery,” the researchers remark.
They say: “Our results will have an immediate impact on patient management, indicating that surgery is a valid and safe option to be considered in patients with hypertension, one of the most important cardiovascular risk factors.”
The CHIRACIC study included 52 patients (median age 63 years, 69% women) with a unilateral adrenal adenoma (mean 3.3 cm), MACS, and hypertension. They were randomly assigned to receive adrenalectomy (n=26) or conservative management (n=26) after a run-in phase to confirm hypertension with multiple home BP measurements (HBPM) then BP normalization with standardized stepped-care antihypertensive treatment.
The researchers report that MACS resolved in all 23 patients who ultimately underwent surgery but 65% developed corticotropic insufficiency, which lasted for a median of 100 days. By contrast, MACS persisted in all 25 conservatively managed patients who completed the study.
In an intention-to-treat analysis carried out after 13 months of follow-up, significantly more participants in the adrenalectomy arm than in the conservative management arm had a reduction in antihypertensive treatment while maintaining normal HBPM (<135/85 mmHg), at 46% versus 15%.
Adrenalectomy was also associated with a significantly greater likelihood of achieving an antihypertensive reduction plus a systolic blood pressure below 130 mmHg during 24 h ambulatory BP monitoring (42 vs 12%).
Of the 23 participants who underwent adrenalectomy and completed the study, 10 (43%) still needed antihypertensive treatment at the end of the study compared with 96% of the 25 who received conservative management.
Around half (52%) of people in the adrenalectomy group were able to stop all antihypertensives while maintaining normal systolic HBPM (<135 mmHg), compared with none following conservative management.
Serious adverse events (SAEs) occurred at a similar rate with adrenalectomy and conservative management (35 vs 31%) and no patients died. Of note, three SAEs among three participants in the adrenalectomy arm were related to the surgery (postsurgical wall pain and hypotension).
Tabarin et al conclude that their findings “support MACS as a cause of secondary hypertension and point to the benefits of adrenalectomy in the treatment of hypertension in patients with unilateral adrenal incidentalomas responsible for MACS.”
They add: “Future studies should identify prognostic factors for surgical success to improve selection of the best candidates for surgery, and confirm the benefits of adrenalectomy on cardiovascular events and life expectancy in long-term follow-up studies involving large cohorts of patients.”
In an accompanying comment, Gail Adler and co-authors, from Harvard Medical School in Boston, Massachusetts, USA, say that, although “[t]he CHIRACIC study has shown a significant benefit of adrenalectomy on maintaining controlled blood pressure with fewer medications in individuals with an adrenal adenoma and MACS,” the findings may not be widely applicable.
“It is important to recognise this was a selected patient population,” they remark. “All participants had relatively large unilateral adrenal adenomas with normal contralateral imaging and confirmed hypertension. Additionally, the study’s inclusion criteria for MACS favoured those with more prominent cortisol production.”
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