John Wayne Cancer Institute, Santa Monica, California.
Department of Surgery, Kaiser Permanente San Jose Medical Center, San Jose, California.
JAMA Surg. 2020 Jan 1;155(1):32-39. doi: 10.1001/jamasurg.2019.3950.
Hyperparathyroidism is associated with cardiovascular disease. However, evidence for a beneficial consequence of parathyroidectomy on hypertension is limited.
To investigate if parathyroidectomy improves hypertension in patients with primary hyperparathyroidism (PHPT).
DESIGN, SETTING, AND PARTICIPANTS: In this cohort study and retrospective database review, patients with PHPT and hypertension between January 1, 2008, and December 31, 2016, were identified. The mean arterial pressure (MAP) and number of antihypertensive medications were compared between those who did and did not undergo parathyroidectomy. The setting was a large health care system. Primary hyperparathyroidism was defined using biochemical data, and hypertension was identified by International Classification of Diseases, Ninth Revision codes.
Parathyroidectomy was identified in the database by Current Procedural Terminology codes.
The MAP and use of antihypertensive medications were compared for patients who underwent parathyroidectomy and those who did not at 6 months, 1 year, and 2 years. Multivariable logistic regression was used to assess the adjusted odds ratios for both increased and decreased use of antihypertensive medications.
In this cohort study of 2380 participants (79.0% female), patients undergoing parathyroidectomy (n = 501) were younger (mean [SD] age, 65.3 [9.7] vs 71.9 [10.4] years; P < .001) and took fewer antihypertensive medications at baseline (mean [SD] number of medications, 1.2 [1.1] vs 1.5 [1.3], P < .001) than nonsurgical patients (n = 1879). Patients with parathyroidectomy showed greater improvement in their MAP at all follow-up time points (the median [SD] MAP change from baseline to 1 year was 0.1 [8.7] mm Hg without parathyroidectomy vs -1.2 [7.7] mm Hg after parathyroidectomy, P = .002). Nonsurgical patients were more likely vs those with parathyroidectomy to require more antihypertensive medications at 6 months (15.9% [n = 298] vs 9.8% [n = 49], P = .001), 1 year (18.1% [n = 340] vs 10.8% [n = 54], P < .001), and 2 years (17.6% [n = 330] vs 12.2% [n = 61], P = .004). By multivariable analysis, parathyroidectomy was independently associated with freedom from an increased number of antihypertensive medications at all periods (eg, adjusted odds ratio, 0.49; 95% CI, 0.34-0.70; P < .001 at 1 year). Among patients who were initially not taking antihypertensive medications, patients with parathyroidectomy were less likely vs no surgery to start antihypertensive medication treatment at all periods (eg, 10.2% [13 of 127] vs 30.4% [136 of 447], P < .001 at 1 year).
This study's findings suggest that, among hypertensive patients with PHPT, parathyroidectomy may be associated not only with greater decreases in their MAP but also with reduced requirements for antihypertensive medications. Parathyroidectomy decreased the number of patients who began taking antihypertensive medications. Additional study will be required to find whether there are downstream cardiovascular benefits of parathyroidectomy. Preexisting hypertension, particularly in those not already taking antihypertensive medications, should be considered when weighing surgical treatment.
甲状旁腺功能亢进与心血管疾病有关。然而，甲状旁腺切除术对高血压有益的证据有限。
研究原发性甲状旁腺功能亢进症（PHPT）患者甲状旁腺切除术是否可改善高血压。
设计、设置和参与者：在这项队列研究和回顾性数据库研究中，确定了 2008 年 1 月 1 日至 2016 年 12 月 31 日期间患有 PHPT 和高血压的患者。比较甲状旁腺切除术患者和未行甲状旁腺切除术患者的平均动脉压（MAP）和降压药物的数量。研究地点为大型医疗保健系统。使用生化数据定义原发性甲状旁腺功能亢进症，通过国际疾病分类第九版代码确定高血压。
数据库中通过当前程序术语代码识别甲状旁腺切除术。
比较了行甲状旁腺切除术和未行甲状旁腺切除术的患者在 6 个月、1 年和 2 年时的 MAP 和降压药物的使用情况。使用多变量逻辑回归评估降压药物使用增加和减少的调整后比值比。
在这项队列研究中，共有 2380 名参与者（79.0%为女性），行甲状旁腺切除术的患者（n=501）年龄较小（平均[标准差]年龄，65.3[9.7]岁 vs 71.9[10.4]岁；P<0.001），基线时服用的降压药物较少（平均[标准差]药物数量，1.2[1.1]种 vs 1.5[1.3]种，P<0.001）。与未行手术的患者（n=1879）相比，行甲状旁腺切除术的患者在所有随访时间点的 MAP 均有更大的改善（未行甲状旁腺切除术的患者从基线到 1 年的 MAP 中位数[标准差]变化为 0.1[8.7]mmHg，而行甲状旁腺切除术的患者为-1.2[7.7]mmHg，P=0.002）。与未行手术的患者相比，行甲状旁腺切除术的患者在 6 个月（15.9%[n=298] vs 9.8%[n=49]，P=0.001）、1 年（18.1%[n=340] vs 10.8%[n=54]，P<0.001）和 2 年（17.6%[n=330] vs 12.2%[n=61]，P=0.004）时需要更多的降压药物的可能性更小。多变量分析显示，在所有时间段，甲状旁腺切除术与不增加降压药物数量独立相关（例如，调整后的比值比，0.49；95%CI，0.34-0.70；P<0.001，在 1 年时）。在最初未服用降压药物的患者中，与未行手术相比，行甲状旁腺切除术的患者在所有时间段开始降压药物治疗的可能性更小（例如，10.2%[13/127] vs 30.4%[136/447]，P<0.001，在 1 年时）。
本研究结果表明，在患有 PHPT 的高血压患者中，甲状旁腺切除术不仅可能导致 MAP 降低幅度更大，而且可能减少降压药物的需求。甲状旁腺切除术减少了开始服用降压药物的患者数量。需要进一步研究以确定甲状旁腺切除术是否有下游心血管益处。在权衡手术治疗时，应考虑到高血压的存在，特别是在那些尚未服用降压药物的患者中。
