Adrenal incidentalomas are benign, lipid rich tumours occurring in 1.4 – 7.2 % of the general population based on imaging studies. Mild autonomous cortisol secretion (MACS) develops in 11.6 – 36.1% of all adrenal incidentalomas. MACS is defined biochemically as a morning cortisol > 50 nmol/L after a 1-mg dexamethasone suppression test and characterised by loss of the circadian rhythm of cortisol secretion. Patients with adrenal incidentaloma and MACS do not have classical clinical features of Cushing’s syndrome. However, observational studies consistently demonstrate a higher prevalence of cardiometabolic disease such as hypertension and diabetes and increased cardiovascular and all-cause mortality. The mechanisms underlying the association between adrenal incidentaloma with MACS and increased cardiometabolic risk have not been fully characterised. Current guidelines recommends medical management of individual cardiometabolic co-morbidities in these patients as the first step in treatment. This presentation will outline potential mechanisms underlying cardiovascular risk in adrenal incidentaloma and MACS and discuss these in the context of recently updated MACS management guidelines.