Primary Aldosteronism Spectrum Linked to Cardiovascular Risk in ARIC

Key Takeaways

• Higher aldosterone-renin ratio was associated with the composite outcome, ischemic stroke, and atrial fibrillation over 9 years.
• Adjusted analyses did not show an association between higher aldosterone-renin ratio and incident heart failure hospitalization or myocardial infarction.
• The authors interpreted this pattern as supporting a spectrum of primary aldosteronism and suggesting relevance of the aldosterone pathway to cardiovascular prevention.

In community-dwelling older adults in the Atherosclerosis Risk in Communities cohort, a higher aldosterone-renin ratio was associated with a 13% higher adjusted risk of ischemic stroke per doubling over 9 years. Atrial fibrillation also increased across higher aldosterone-renin ratio levels in this prospective cohort analysis. The study evaluated observed associations rather than treatment effects.

This prospective ARIC cohort analysis measured serum aldosterone and renin during 2011 to 2013. Investigators used longitudinal Cox regression analyses from March to September 2025 among participants free of heart failure, myocardial infarction, stroke, and potassium-sparing diuretic use at baseline. The cohort included 3477 individuals with a mean age of 74.8 years, and 61.5% were female. Exposures were serum aldosterone level and aldosterone-renin ratio, with median values of 5.1 ng/dL, 0.78 ng/mL per hour, and 5.9 ng/dL per ng/mL/h, respectively. Prespecified outcomes were incident heart failure hospitalization, atrial fibrillation, ischemic stroke, myocardial infarction, and a composite of these events plus all-cause death.

Over follow-up, higher aldosterone-renin ratio was associated with the composite outcome, with an adjusted hazard ratio of 1.04 per doubling (95% CI, 1.01 to 1.08). The adjusted hazard ratio was 1.13 for ischemic stroke (95% CI, 1.02 to 1.26) and 1.10 for atrial fibrillation (95% CI, 1.05 to 1.15). No adjusted association was seen for heart failure hospitalization, with a hazard ratio of 1.02 (95% CI, 0.96 to 1.07), or for myocardial infarction, with a hazard ratio of 1.01 (95% CI, 0.92 to 1.12).

The investigators interpreted these findings as evidence for a spectrum of primary aldosteronism in older adults. In their interpretation, the association pattern supports the aldosterone pathway as a potential target for cardiovascular prevention. The abstract did not describe treatment or safety data, and the findings were limited to this older ARIC cohort.