Abstract
Cardiovascular disease (CVD) is the most common cause of death in the world. Recent studies have shown an association between adrenal insufficiency (AI) and increased cardiovascular risk (CVR). Patients with AI receive glucocorticoid (GC) replacement therapy which can lead to varying levels of blood cortisol. It was shown that these imbalances in blood cortisol may lead to a higher prevalence of coronary heart disease, major adverse coronary events, and increased mortality. GC substitution is essential in the treatment of AI without which the disease has been shown to be fatal. The most frequently used GC formula for replacement therapy is hydrocortisone (HC). There is no uniform opinion on hydrocortisone replacement therapy. Alternative GC such as prednisolone is also in use. Overreplacement of GC may lead to adverse effects including obesity, high blood pressure, and hyperglycaemia. Outcome may vary between primary and secondary AI mainly due to differences in the renin-angiotensin-aldosterone system (RAAS). Furthermore, decreased blood levels of cortisol may lead to a compensatory secretion of inflammatory mediators such as Interleukin-1 (IL-1), Interleukin-6 (IL-6), and/or tumor-necrosis factor (TNF). Physicians and patients should be properly educated about the increased risk of CVD in patients with AI.
Highlights
Cardiovascular disease (CVD) is the most common cause of death in the world
Recent studies have shown an association between adrenal insufficiency (AI) and increased cardiovascular risk (CVR)
Reduction of the HC dose by as much as 50% resulted in a significant weight loss of up to 7 kg in one year while blood pressure, fasting glucose, and insulin levels remained unaffected [18, 19]
Summary
Primary adrenal insufficiency (AI) is a rare disease with a prevalence of approximately 100 to 126 cases per million in Western countries [1,2,3]. While in developed countries the leading etiology of primary AI is autoimmune disease, tuberculosis associated adrenalitis remains an important cause in developing countries [4, 5]. Certain drugs such as mitotane, ketoconazole, metyrapone, and etomidate may lead to primary adrenal insufficiency due to their inhibiting effect on adrenal enzymes [6]. ACTH-deficiency in the pituitary gland results in secondary AI with an estimated prevalence of 45.5 per 100,000 [7]. Both types of AI lead to a lack of endogenous glucocorticoids (GC), while absence of mineralocorticoids is limited to primary AI. The following review attempts to depict the cardiovascular risk (CVR) in patients with AI receiving GC replacement therapy
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