cAMP/PKA signaling in endocrine hypertension: genetic mechanisms and pathophysiological insights

The cyclic adenosine monophosphate (cAMP)-protein kinase A (PKA) signaling pathway plays a central role in adrenal function, steroidogenesis, and blood pressure regulation. Increasing evidence suggests that dysregulation of this pathway contributes to several forms of hypertension, both endocrine and non-endocrine. A growing number of germline and somatic alterations affecting components of the cAMP/PKA axis have been implicated as key drivers of hypertensive disorders. Among these, activating pathogenic variants (PV) in <i>GNAS</i>, which encodes the stimulatory G protein α-subunit (Gsα) responsible for cAMP production, have been linked to cortisol excess. Mosaic <i>GNAS</i> PV <i>cause McCune-Albright syndrome</i>, which may present with ACTH-independent Cushing syndrome, while somatic <i>GNAS</i> PV have been identified in cortisol-producing adrenal adenomas. Germline inactivating variants in <i>PRKAR1A</i> are associated with <i>Carney complex and primary pigmented nodular adrenocortical disease (PPNAD).</i> Furthermore, germline alterations in phosphodiesterases such as <i>PDE11A</i> and <i>PDE8B</i>, which impair cAMP degradation, have been associated with Cushing syndrome and micronodular adrenal hyperplasia. Somatic activating PV in <i>PRKACA</i>, the gene encoding the catalytic subunit of PKA, have also been described in cortisol-producing adenomas. In primary aldosteronism, recent studies-including data from our group-suggest that germline variants in <i>PDE2A</i> and <i>PDE3B</i> may contribute to bilateral adrenal hyperplasia and autonomous aldosterone production by modulating intracellular cAMP levels. Additionally, gain-of-function PV in <i>PDE3A</i> have been associated with a familial form of salt-independent hypertension characterized by enhanced PKA signaling and vascular remodeling. This expanding body of evidence underscores the critical role of the cAMP/PKA pathway in the pathophysiology of distinct hypertensive phenotypes and highlights novel molecular mechanisms and potential therapeutic targets that merit further investigation.