Surgery for the treatment of arterial hypertension in patients with unilateral adrenal incidentalomas and mild autonomous cortisol secretion (CHIRACIC): a multicentre, open-label, superiority randomised controlled trial.

Summary

In this multicentre RCT of hypertensive patients with MACS and unilateral adrenal incidentalomas, adrenalectomy led to a higher proportion achieving normal home blood pressure with reduced antihypertensive therapy versus conservative care (46% vs 15%; adjusted RD 0.34; p=0.0038). The surgery group required fewer and lower-intensity medications, with supportive ABPM changes and similar rates of serious adverse events.

Key Findings

• Primary endpoint achieved more often with adrenalectomy: 46% vs 15% with conservative care (adjusted RD 0.34; p=0.0038).
• Fewer patients required antihypertensive therapy after surgery (43% vs 96% still on treatment at study end); mean treatment step was markedly lower (−2.05).
• 24-hour ABPM improvements paralleled HBPM findings; serious adverse events were similar between groups, with three surgery-related events.

Clinical Implications

For hypertensive patients with unilateral incidentalomas and MACS, minimally invasive adrenalectomy should be actively considered to reduce medication burden and normalize BP, with structured pre/postoperative BP assessment.

Limitations

• Open-label design may introduce performance bias.
• Modest sample size after run-in and limited to 13 months; generalizability beyond trial criteria requires caution.

Future Directions

Assess long-term cardiovascular outcomes, metabolic effects (e.g., diabetes risk), and cost-effectiveness of surgical versus medical management in MACS.