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‘Modest’ BP Benefits Tied to Hyperparathyroid Surgery

Parathyroidectomy in patients with primary hyperparathyroidism (PHPT) and concomitant hypertension was linked with improved cardiovascular measures and less reliance on antihypertensives, a retrospective study found.

At 1 year, those who received parathyroidectomy had a modest reduction in mean arterial pressure (MAP), with a 1.2 mm Hg drop in median MAP compared with an increase of 0.1 mm Hg in the non-surgery group (P=0.002), Meena Said, MD, of the John Wayne Cancer Institute in Santa Monica, California, and colleagues reported in JAMA Surgery.

Among the nearly 2,400 patients included in the analysis, significantly fewer individuals who underwent surgery needed extra antihypertensive medications, and at multiple time points, compared with those who received nonsurgical management:

  • 6 months: 9.8% vs 15.9%
  • 1 year: 10.8% vs 18.1%
  • 2 years: 12.2% vs 17.6%

In a multivariable analysis, surgery patients were 50% less likely to need any extra blood pressure medication at 1 year (adjusted odds ratio 0.49, 95% CI 0.34-0.70, P<0.001). Similarly, only about 10% of antihypertensive-naive patients who underwent parathyroidectomy ended up needing to initiate antihypertensive medication treatment at this time point versus 30% of nonsurgical patients.

“Antihypertensive medication use is a relevant clinical factor that reflects the association of parathyroidectomy with hypertension,” Said’s group wrote, noting too that for individuals hovering on borderline hypertension that might require medication in the imminent future, “parathyroidectomy may allow them to avoid initiating treatment.”

They added that “parathyroidectomy may also have implications at the population level, allowing for more cost-effective care by preventing antihypertensive medication use and reducing the use of associated healthcare resources.”

Wen Shen, MD, of the University of California San Francisco, called the study “timely” in an accompanying commentary, and praised the researchers for shedding light on the sometimes overlooked cardiovascular implications associated with primary hyperparathyroidism.

“The organs most likely to be negatively affected by PHPT are the bones, kidneys, brain, and heart. Medical students everywhere still learn about the effects of this disease on the first three: who will ever forget the stones/bones/groans mnemonic?” Shen wrote. “But it is the heart that typically gets left out of the discussion, even though compelling evidence has mounted over the decades demonstrating the serious cardiovascular consequences of PHPT, including ventricular hypertrophy, vascular calcifications, and increased risk for significant cardiac events, such as stroke, heart failure, and myocardial infarction.”

However, Shen also pointed out that the findings, though statically significant, were “modest at best” and “not as profound as one might hope” — particularly with regard to the minimal decrease in MAP.

He advised surgeons to keep the possible adverse cardiovascular outcomes in the conversation when discussing treatment options for patients with primary hyperparathyroidism, but these should be weighed against other individual risks and benefits.

He concluded posing the question: “If parathyroidectomy was a new antihypertensive drug and you were a pharmaceutical company, would you buy or sell?”

For their analysis, Said and colleagues looked at patients appearing in the Kaiser Permanente Southern California Region database from 2008 to 2016. Primary hyperparathyroidism was defined as a parathyroid hormone (PTH) level over 65 pg/mL within 6 months of an elevated serum calcium level over 10.5 mg/dL. Concurrent hypertension was identified by ICD-9 code. Individuals who opted for parathyroidectomy (n=501) tended to be younger than the nonsurgical group (n=1,879) and have a higher average baseline PTH level (149.0 vs 104.7 pg/mL, respectively).

Last Updated October 09, 2019

Said had no disclosures. One co-author reported relationships with Novartis, Pulse Biosciences, Castle Biosciences, Bristol-Myers Squibb, and Delcath Systems.