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Serum Aldosterone, Plasma Renin Activity, and Ambulatory BP in African Americans
Quick Takes
- In African Americans, plasma renin activity (PRA) was negatively associated and aldosterone:renin ratio (ARR) was positively associated with clinic, awake, and asleep SBP and DBP and multiple ambulatory blood pressure monitoring (ABPM) phenotypes.
- Providers should be aware of the importance of low PRA in multiple ABPM phenotypes including daytime, nocturnal, daytime and nocturnal, and sustained hypertension in African Americans.
- Until there is further trial evidence, the study suggests the very cost-effective and safe potassium-sparing aldosterone antagonists should be considered early in the treatment of hypertension in African Americans with high aldosterone:renin ratio and the epithelial sodium channel inhibitors in African Americans with low aldosterone/low renin phenotypes.
Study Questions:
What is the relationship between the renin-angiotensin-aldosterone system (RAAS) and ambulatory blood pressure (ABP) and ABP monitoring (ABPM) phenotypes among African Americans?
Methods:
ABP and ABPM phenotypes were assessed in 912 Jackson Heart Study participants with aldosterone and plasma renin activity (PRA). Multivariable linear and logistic regression analysis were used to analyze the association of aldosterone and PRA with clinic, awake, and asleep systolic BP (SBP) and diastolic BP (DBP) and ABPM phenotypes, adjusting for important confounders.
Results:
The mean age of participants was 59 ± 11 years and 69% were female. In fully adjusted models, lower log-PRA was associated with higher clinic, awake, and asleep SBP and DBP (all p < 0.05). A higher log-aldosterone was associated with higher clinic, awake, and asleep DBP (all p < 0.05). A 1-unit higher log-PRA was associated with lower odds of daytime hypertension (odds ratio [OR], 0.59; 95% confidence interval [CI], 0.49-0.71), nocturnal hypertension (OR, 0.68; 95% CI, 0.58-0.79), daytime and nocturnal hypertension (OR, 0.59; 95% CI, 0.48-0.71), sustained hypertension (OR, 0.52; 95% CI, 0.39-0.70), and masked hypertension (OR, 0.75; 95% CI, 0.62-0.90). A 1-unit higher log-aldosterone was associated with higher odds of nocturnal hypertension (OR, 1.38; 95% CI, 1.05-1.81). Neither PRA nor aldosterone were associated with percent dipping, non-dipping BP pattern, or white-coat hypertension. Patterns for aldosterone:renin ratio were similar to PRA.
Conclusions:
Suppressed renin activity and higher aldosterone:renin ratios were associated with both higher SBP and DBP in the office and during the awake and asleep periods, as evidenced by ABPM. Higher aldosterone levels were associated with higher DBP, but not SBP, in the clinic and during the awake and asleep periods. Further clinical investigation of novel and approved medications that target low renin physiology such as epithelial sodium channel inhibitors and mineralocorticoid receptor antagonists may be paramount in improving hypertension control in African Americans.
Perspective:
Aldosterone antagonists (spironolactone and eplerenone) and potassium-sparing diuretics known as epithelial sodium channel inhibitors (amiloride and triamterene) are generally not the antihypertensives of first choice but often the second or third drug. They are as effective in African Americans as in Whites. These agents are generic and relatively safe. This Jackson Heart Study suggests they may be very effective in African Americans including 24-hour BP control and deserve another look.
Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Heart Failure and Cardiomyopathies, Prevention, Vascular Medicine, Lipid Metabolism, Novel Agents, Hypertension
Keywords: African Americans, Aldosterone, Antihypertensive Agents, Blood Pressure, Blood Pressure Monitoring, Ambulatory, Blood Pressure Monitors, Diuretics, Potassium Sparing, Hypertension, Masked Hypertension, Mineralocorticoid Receptor Antagonists, Primary Prevention, Renin, Renin-Angiotensin System, White Coat Hypertension
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