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Evaluation and Management of Primary Hyperparathyroidism¹

Endocrinology and Internal Medicine Specialists Marietta, Georgia 30060

I would like to offer a counterpoint to the approach that Drs. Silverberg and Bilezikian (1) have adopted for their patients with hyperparathyroidism as documented in the June 1996 Journal.

In their article, describing their extensive personal experience in the evaluation and management of primary hyperparathyroidism, they separate their patients into symptomatic and asymptomatic groups. In addition to adopting the Surgical Consensus Development Conference in the management of their asymptomatic hyperparathyroid patients, they have added two more criteria, one on vitamin D levels and the other on vertebral bone mass, which they utilize to decide on definitive surgical treatment. This approach leaves 49% of their hyperparathyroid patients untreated.

I feel that this leaves this group of hypercalcemic patients at risk of morbidity and mortality from cardiovascular disease and hence reduced survival. There is an abundant amount of information in the literature over the past 10 yrs documenting reduced survival in hypercalcemic patients, primarily from cardiovascular diseases.

Dr. Palmer, et al. (2) demonstrated decreased survival over a 14-yr followup in untreated patients with hypercalcemia that were not from malignancies. Their mortality was mainly from cardiovascular deaths. Dr. Palmer, et al. (3) demonstrated a reduced cumulative survival for patients with hyperparathyroidism even after surgery, perhaps being related to the duration of hypercalcemia before treatment, as it took 2 yrs of hypercalcemia to qualify for the diagnosis of hyperparathyroidism. Dr. Stefenelli, et al. (4) presented data obtained from a group of patients with hyperparathyroidism showing a high incidence of left ventricular hypertrophy along with myocardial calcifications and valvular calcifications that again perhaps contribute to the increased cardiovascular morbidity and mortality. Dr. Niederle, et al. (5), in following 212 consecutive patients treated for hyperparathyroidism, demonstrated reduced survival of these patients compared with their age-matched and sex-matched controls, again related to cardiovascular morbidity and mortality.

In the same issue of JCEM as Drs. Silverberg and Bileziklan’s article is a paper by Drs. Leifsson and Ahren (6) demonstrating increased risk of premature death in men related to serum calcium levels that are within the normal range, again cardiovascular disease accounting for these premature deaths.

Drs. Silverberg and Bilezikian’s approach to hyperparathyroidism would be similar to an approach in hypercholesterolemia that withholds treatment until after the angina has occurred. Instead of leaving a large number of patients with hypercalcemia untreated until they develop symptoms or meet bone mineral density or vitamin D level criteria, I would propose that all patients with hyperparathyroidism be surgically cured as soon as the disease is documented, to protect them from the morbidity and mortality of cardiovascular disease that hypercalcemia is known to induce.

Footnotes

¹ Address correspondence to: S.J. Rosenbloom, Department of Medicine, Endocrinology and Internal Medicine Specialists, 790 Church Street, Suite 400, Marietta, Georgia 30060.

Received December 4, 1996.

References

1. Silverberg S, Bilezikian J. 1996 Extensive personal experience: Evaluation and management of primary hyperparathyroidism. J Clin Endocrinol Metab. 81:2036–2040.[CrossRef][Medline]
2. Palmer M, Bergstrom R, Akerstrom G, Adami H, Jakobsson S, Ljunghall S. 1987 Survival and renal function in untreated hypercalcemia. Lancet. 59–62.
3. Palmer M, Adami H, Bergstrom R, Akerstrom G, Ljunghall S. 1987 Mortality after sugery for primary hyperparathyroidism: a follow-up of 441 patients operated on from 1956 to 1979. Surgery. 102:1–7.[Medline]
4. Stefenelli T, Mayer H, Bergier-Klein J, Globits S, Wolszczuk W, Niederle B. 1992 Primary hyperparathyroidism: incidence of cardiac abnormalities and partial reversibility after successful parathyroidectomy. Am J Med. 95:197–202.
5. Niederle B, Roka R, Wolszczuk W, Klaushofer K, Kovarik J, Schernthaner G. 1987 Successful parathyroidectomy and primary hyperparathyroidism: A clinical followup study of 212 consecutive patients. Surgery. 903–909.
6. Leifsson B, Ahren B. 1996 Serum calcium and survival in a large health screening program. J Clin Endocrinol Metab. 81:2149–2153.[Abstract]

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