Cardiovascular and metabolic risk factors in patients with subclinical Cushing

Endocrine. 2020 Oct;70(1):150-163. doi: 10.1007/s12020-020-02297-2. Epub 2020 Apr 16.


Purpose: Adrenal incidentalomas (AI) are discovered after work-up unrelated to adrenal gland diseases; up to 30% of AI show subclinical endogenous cortisol excess (SH), frequently associated to hypertension, obesity, metabolic disorders and increased incidence of cardiovascular events (CVEs).

Methods: We analysed 628 AI patients divided into two groups: 471 non-functional adrenal adenoma (NFA) and 157 SH. All patients underwent complete examinations, 24-h ambulatory blood pressure monitoring, biohumoral parameters and vascular damage markers, such as c-IMT and ankle brachial index. After long-term follow-up, we registered newly onset of CVEs such as myocardial infarction (MI), percutaneous stenting and surgical bypass (PTA/CABG), stroke, overall/cardiovascular mortality. Moreover, SH patients underwent to surgical (SSH) or pharmacological treatment (MSH).

Results: SH patients showed higher prevalence of metabolic syndrome, diabetes mellitus, and previous CVEs respect NFA at baseline. After follow-up MSH group showed higher recurrence of major CV events compared with NFA and SSH (RR 2.27 MSH vs NFA for MI; RR 2.30 MSH vs NFA for PTA/CABG; RR 2.41 MSH vs NFA for stroke). In SSH there was a significant reduction of the number of antihypertensive medications needed to reach target blood pressure levels (2.3 ± 1.0 to 1.5 ± 0.4 drugs). None differences were found in SH patients, distinguished in relation to cortisol plasma levels after dexamethasone suppression test (1.8-5 µg/dL, above 5 µg/dL).

Conclusions: SH is linked to relevant cardiovascular and metabolic alterations, leading to worsen clinical outcomes. In eligible patients, adrenalectomy is valid and safe option to treat SH, reducing cardiometabolic abnormalities.

Keywords: Atherosclerosis; Cardiovascular risk; Glucose metabolism; Metabolic syndrome; Subclinical Cushing.

MeSH terms

  • Adrenal Gland Neoplasms*
  • Blood Pressure Monitoring, Ambulatory
  • Cardiovascular Diseases / epidemiology
  • Humans
  • Hydrocortisone
  • Hypertension / epidemiology
  • Neoplasm Recurrence, Local
  • Obesity / epidemiology
  • Pituitary ACTH Hypersecretion* / complications
  • Risk Factors


  • Hydrocortisone