MACS affects 26.2% of primary aldosteronism patients and tracks with higher cardiometabolic oddsMild Cortisol Secretion Linked to Heart Risks in Aldosteronism

Journal of hypertension Published October 2, 2026 Study authors: Eisa Naseem, Khoury Mira PubMed ↗ DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

Consider DST screening for MACS in PA; interpret cardiometabolic odds cautiously.

This meta-analysis examined the co-occurrence of mild autonomous cortisol secretion (MACS) in patients with primary aldosteronism (PA), pooling data from 2356 patients. The primary outcome was the pooled prevalence of MACS in PA, estimated at 26.2% (95% CI 24.1-28.4; I2 = 24.2%; prediction interval 21.6-31.4%).

For secondary cardiometabolic outcomes, MACS co-occurrence was associated with higher odds of cardiovascular events (OR 1.60; 95% CI 1.07-2.38; P = 0.021) and type 2 diabetes mellitus (OR 1.37; 95% CI 1.00-1.86; P = 0.048). Obesity was not significantly associated with MACS (OR 1.10; P = 0.411).

The authors note moderate certainty for the prevalence estimate and low certainty for the cardiovascular event association. The association between MACS and cardiovascular events is reported as an odds ratio and does not establish a direct causal link. Obesity was not significantly associated with MACS. Safety outcomes, including adverse events and discontinuations, were not reported. Funding and conflicts of interest were not reported.

The findings support routine dexamethasone suppression testing (DST) screening in PA and have implications for perioperative management and cardiometabolic risk stratification. Clinicians should interpret the cardiometabolic associations cautiously given the low certainty for cardiovascular events and the observational nature of the pooled data.

How this fits prior evidence

This meta-analysis extends prior coverage of primary aldosteronism, which has been associated with lower serum potassium and higher urinary albumin excretion despite similar eGFR. It also aligns with prior evidence that cardiometabolic risk factors, such as those addressed by dietary and gut microbiota interventions, influence outcomes in older adults. The finding that MACS co-occurs in 26.2% of PA patients and is associated with higher odds of cardiovascular events and type 2 diabetes adds a specific hormonal screening consideration to the existing PA risk profile. The low certainty for cardiovascular events contrasts with the more established associations previously reported.

Researchers analyzed data from over 2,300 patients with primary aldosteronism (PA) to see how mild autonomous cortisol secretion (MACS) affects health. The study found that about 26.2% of these patients had this specific type of cortisol secretion.

For those with both conditions, the data showed a link to higher odds of cardiovascular events and type 2 diabetes. However, the study did not find a significant link between this cortisol secretion and obesity. Because the evidence for heart events was based on a small amount of data, the certainty of that specific finding is low.

These findings suggest that doctors may need to screen for cortisol levels more often in patients with primary aldosteronism. This can help them better manage risks related to heart health and diabetes. Patients should talk to their doctors about how these specific findings apply to their personal health plan.

What this means for you:

Patients with primary aldosteronism and mild cortisol secretion may have higher risks for heart issues and diabetes.

Common questions

What is the link between cortisol and heart health in these patients?

The study found that patients with both primary aldosteronism and mild autonomous cortisol secretion (MACS) had higher odds of cardiovascular events. This was measured as an odds ratio of 1.60. However, the researchers noted that this is a reported association and not a direct causal link. The certainty for this specific finding was low.

Does this condition affect weight or obesity?

The study looked at the link between mild autonomous cortisol secretion and obesity. The results showed no significant difference in obesity levels between the groups studied. This means that, based on this data, the presence of extra cortisol did not appear to be linked to higher rates of obesity.

How common is this cortisol secretion in patients with aldosteronism?

The analysis found that approximately 26.2% of patients with primary aldosteronism also had mild autonomous cortisol secretion. This finding had a moderate level of certainty. Doctors may use this information to help decide when to perform specific screenings for their patients.

Study Details

Study typeMeta analysis

Sample sizen = 2,356

EvidenceLevel 1

PublishedOct 2026

PMID42554261

View Original Abstract ↓

Many primary aldosteronism (PA) patients harbor concomitant mild autonomous cortisol secretion (MACS), termed "Connshing syndrome." The prevalence and cardiometabolic impact of this co-secretion have not been quantitatively synthesized. To determine the pooled prevalence of MACS in PA and evaluate its association with cardiovascular (CV) events, type 2 diabetes mellitus (T2DM), and obesity. PubMed, Embase, Cochrane, Web of Science, and Scopus through January 2026. Following PRISMA 2020 and MOOSE guidelines (PROSPERO: CRD420261334965), studies reporting MACS prevalence [post-1 mg dexamethasone suppression test (DST) cortisol ≥1.8 μg/dl] in PA were included. Prevalence was pooled using random-effects models. Odds ratios (ORs) were calculated for cardiometabolic outcomes. Certainty was evaluated using GRADE. Fourteen studies (2356 patients) were included. Pooled MACS prevalence was 26.2% [95% confidence interval (CI): 24.1-28.4; I2 = 24.2%; prediction interval: 21.6-31.4%], consistent across European (27.0%) and East Asian (25.2%) cohorts ( P = 0.62). MACS + PA patients had higher odds of CV events (OR 1.60; 95% CI: 1.07-2.38; P = 0.021) and T2DM (OR 1.37; 95% CI: 1.00-1.86; P = 0.048), but not obesity (OR 1.10; P = 0.411). Sensitivity analyses confirmed robustness. GRADE certainty was moderate for prevalence and low for CV events. Approximately one in four PA patients has MACS, associated with a 60% higher CV event risk. These findings support routine DST screening in PA and have implications for perioperative management and cardiometabolic risk stratification.

MACS affects 26.2% of primary aldosteronism patients and tracks with higher cardiometabolic oddsMild Cortisol Secretion Linked to Heart Risks in Aldosteronism

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Common questions

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