Renin-Guided Risk Stratification and Therapy in Hypertension to Reduce Major Adverse Cardiovascular Outcomes

Area of Science:

• Cardiovascular Medicine
• Endocrinology
• Hypertension Research

Background:

• Risk stratification in hypertension is complex, with the prognostic role of plasma renin activity (PRA) in guiding therapy not fully established.
• Understanding PRA's association with cardiovascular events is crucial for optimizing hypertension management.

Purpose of the Study:

• To investigate the prognostic value of plasma renin activity in predicting major adverse cardiovascular events (MACE).
• To evaluate differential treatment responses to mineralocorticoid receptor antagonists (MRAs) and renin-angiotensin system inhibitors (RASIs) based on renin levels.

Main Methods:

• A multicenter retrospective cohort study involving 16,600 patients with hypertension.
• Analysis of plasma renin activity as a continuous variable using restricted cubic splines.
• A 6-month landmark analysis comparing MRA initiation versus baseline RASI use.

Main Results:

• A U-shaped association was observed between continuous renin levels and MACE, with the lowest risk at 1.17 ng/mL/h.
• Both low (<0.3 ng/mL/h) and high (>3.0 ng/mL/h) renin levels were independently associated with increased MACE risk.
• MRA initiation showed a graded risk reduction, most pronounced in low-renin patients (HR=0.75), while RASI use benefited high-renin patients (HR=0.76).

Conclusions:

• Plasma renin activity serves as a prognostic biomarker for MACE in hypertension.
• A renin-guided treatment strategy, favoring MRAs in low-renin and RASIs in high-renin hypertension, may personalize care and reduce cardiovascular risk.