How does the cause decide the treatment?
Endocrine hypertension is pressure driven by a hormone, so treatment is aimed at the hormonal excess that raises blood pressure, either by removing it or by blocking it. Which of the two applies depends on the cause that was found, and the diagnosis of that cause is what makes this choice possible. For some causes surgery is curative. For others medical treatment is definitive. For several causes, surgery and medical treatment are used together.
Primary aldosteronism: one gland or both?
Aldosterone excess is the cause the earlier notes met first, and its treatment hangs on where the aldosterone comes from: one adrenal gland or both.
Unilateral disease means a single source, either an aldosterone-producing adenoma or unilateral hyperplasia. Removing that gland removes the excess, so laparoscopic adrenalectomy is recommended. Because only one gland should come out, the surgeon has to know which side is responsible. Adrenal venous sampling is used beforehand to confirm this, so that the correct gland is removed.
When both glands are involved, surgery is not recommended. Taking out one gland would leave the other still overproducing, so the excess is blocked instead of removed. The treatment is a mineralocorticoid receptor antagonist. Spironolactone is preferred, and eplerenone is the alternative when spironolactone is not tolerated.
The drug works at the same receptor that aldosterone uses in the distal nephron to reclaim sodium and lose potassium. Blocking the receptor at the kidney prevents aldosterone from retaining sodium, so blood pressure and potassium fall back toward normal.
Pheochromocytoma: why must the patient be prepared before surgery?
Surgery is the definitive treatment for pheochromocytoma and paraganglioma, but it is also the one place where the cure itself is dangerous, and the patient must be prepared for it. A pheochromocytoma is a catecholamine-secreting adrenal tumour, and a paraganglioma is related to it.
Two things have been happening before the operation. Long-standing catecholamine excess leaves the circulation volume-contracted. Catecholamines constrict vessels, so the blood volume sits in a smaller space even though the patient is hypertensive. The same long-standing excess leaves the blood vessels primed to constrict, since catecholamines act on alpha receptors to constrict vessels. Then, during the operation, handling the tumour can release a surge of catecholamines. A circulation primed in this way can swing into a hypertensive crisis.
That is why every patient with a functional pheochromocytoma or paraganglioma is given preoperative alpha blockade. It blunts the vasoconstriction before the surge arrives. The drug is phenoxybenzamine, or doxazosin as an alternative. The blockade is given together with a high-sodium diet and generous fluid intake, to refill the contracted circulation.
A beta blocker is added only after alpha blockade is established, and only if needed for tachycardia. The order matters. Giving a beta blocker first is dangerous: it removes beta-mediated vasodilation while leaving alpha-mediated vasoconstriction unopposed, and this can precipitate the very crisis the preparation is meant to prevent.
Once the patient is prepared, the approach to the tumour depends on its type. Most pheochromocytomas are resected by minimally invasive adrenalectomy, while most paragangliomas need open resection.
Hypercortisolism and thyroid disease: does correcting the hormone fix the pressure?
Here the treatment is to correct the hormone source, starting with cortisol.
Hypercortisolism means excess cortisol, as in Cushing syndrome. The aim is to normalise cortisol, usually by treating the underlying cause. That means surgery on the pituitary or adrenal source. When surgery is not possible or not curative, medical therapy or radiotherapy is used. Blood pressure falls in most patients once the cortisol excess is corrected, which fits cortisol acting on pressure through several mechanisms. But blood pressure often does not normalise completely, so the hypertension itself still needs treatment. The cardiovascular risk that accompanies Cushing syndrome also needs ongoing management.
Hypothyroidism and hyperthyroidism are also endocrine causes of hypertension, though they are less common than primary aldosteronism. Treatment is treatment of the thyroid disorder, and correcting the hormone level usually corrects blood pressure as well.
Acromegaly: what does it add?
Growth hormone and IGF-1 excess in acromegaly raise blood pressure. They do so partly by retaining sodium and expanding plasma volume. The review literature describes the mechanism as seemingly multifactorial, with increased plasma volume the main contributor.
Transsphenoidal surgery is first-line treatment for acromegaly, since the pituitary adenoma is the source and is reached through the nose. When growth hormone excess is controlled, blood pressure improves to some degree. Because the volume expansion eases, blood pressure improves. Other contributors may persist, which is a proposed explanation for why hypertension may not fully reverse.
If the hormone is corrected and the pressure is still high, what is left to treat?