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Prevalence and associated factors of subclinical hypercortisolism in patients with resistant hypertension

Martins, Leonam C.; Conceição, Flavia L.; Muxfeldt, Elizabeth S.; Salles, Gil F.

doi: 10.1097/HJH.0b013e3283521484
ORIGINAL PAPERS: Resistant and malignant hypertension

Background: Subclinical hypercortisolism is a secondary cause of hypertension that had never been evaluated in resistant hypertensive patients, a subgroup of general hypertensive individuals with an expected high prevalence of secondary hypertension.

Methods: Four hundred and twenty-three patients with resistant hypertension and ages up to 80 years were screened for the presence of subclinical hypercortisolism by morning serum cortisol after a midnight 1 mg dexamethasone suppression test (DST). Those with morning cortisol of at least 50 nmol/l had hypercortisolism confirmed by two salivary cortisol of at least 3.6 nmol/l collected at 2300 h. Statistical analysis included bivariate tests between those with positive and negative screening test and with and without confirmed hypercortisolism, and logistic regressions to assess their independent correlates.

Results: One hundred and twelve patients (prevalence 26.5%, 95% confidence interval 22.0–31.9%) had the screening test positive for suspected hypercortisolism. None had overt Cushing syndrome. Patients with positive screening were older, more frequently males, had higher prevalences of diabetes and target-organ damage and higher nighttime SBPs than patients with normal screening test results. Thirty-four patients (total prevalence 8.0%, 95% confidence interval: 5.7–11.2%) had confirmed hypercortisolism. Independent correlates of a positive DST were older age (P = 0.007), male sex (P = 0.012) and presence of cardiovascular diseases (P = 0.002) and chronic kidney disease (P = 0.016). Correlates of confirmed subclinical hypercortisolism were older age (P = 0.020), diabetes (P = 0.06) and a nondipping pattern on ambulatory blood pressure monitoring (P = 0.04).

Conclusion: Patients with resistant hypertension had a relatively high prevalence of subclinical hypercortisolism, and its presence is associated with several markers of worse cardiovascular prognosis.

Department of Internal Medicine, University Hospital Clementino Fraga Filho, Faculdade de Medicina, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Rio de Janeiro, Brazil

Correspondence to Gil F. Salles, Rua Croton, 72 Jacarepagua, Rio de Janeiro, RJ 22750-240, Brazil. Tel: +55 21 2447 3577; fax: +55 21 2562 2514; e-mail:

Abbreviations: ABPM, ambulatory blood pressure monitoring; ARR, aldosterone-to-renin ratio; BP, blood pressure; CHD, coronary heart disease; CI, confidence interval; DST, dexamethasone suppression test; LVMI, left ventricular mass index; PWV, pulse wave velocity

Received 15 November, 2011

Revised 3 January, 2012

Accepted 1 February, 2012

Part of this study was presented in the High Blood Pressure Research 2011 Scientific Sessions, jointly sponsored by the Inter-American Society of Hypertension and American Heart Association's Council for High Blood Pressure Research and the Council on Kidney in Cardiovascular Disease; 2011; in Orlando, Florida, USA.

© 2012 Lippincott Williams & Wilkins, Inc.