Endocrine Abstracts

Introduction: Cushing’s syndrome is a known risk factor for aortic dissection but the association of these conditions is rare. Hypercortisolism is associated with an increased risk of cardiovascular disease and accounts for the high morbidity & mortality in untreated patients.

Case Study: A 64y old male presented with acute onset chest pain, radiating to the back. CT angiogram showed Stanford Type B dissection involving the distal aortic arch/descending aorta and bilateral adrenal hyperplasia. Past medical history included type 2 diabetes, CKD & hypertension. On examination, he had extensive skin bruising, centripetal obesity and was clinically hypogonadal. Visual field assessment showed a left upper quadrant temporal field defect. Severe hypertension in the context of the acute dissection and adrenal hyperplasia led to further investigation of secondary hypertension. Investigations showed ACTH dependent hypercortisolism with loss of diurnal variation (ACTH 340; urine free cortisol 5919). Pituitary MR showed a large macroadenoma (22 mm) causing chiasmal compression. The dissection was managed conservatively (target systolic BP 110-120 mmHg). Adrenolytic treatment with metyrapone was commenced to control severe hypertension and hypercortisolism preoperatively. Despite escalating doses of multiple antihypertensive drugs, BP control was suboptimal (systolic150-170 mmHg). This posed an ongoing risk for further dissection. In view of this and given that hypertension was driven by severe hypercortisolism, the patient underwent transsphenoidal pituitary surgery as an inpatient. Blood pressure normalised to 120-130 mmHg systolic after pituitary surgery.

Discussion: Hypercortisolism results in decreased collagen strength, synthesis, and increased capillary fragility. Only a few cases report the association of Cushing’s syndrome as a likely precipitant of acute aortic dissection. This case highlights the challenges of balancing tight BP control to reduce extension of aortic dissection with the risk of potentially precipitating hypotensive pituitary apoplexy. This case exemplifies critical issues in the pharmacological management of blood pressure in a complex, high risk hypertensive patient.