Higher Aldosterone-Renin Ratio Linked to AF and Stroke Risk in Older Adults: ARIC Study
USA: A higher aldosterone-renin ratio (ARR), reflecting a broader spectrum of primary aldosteronism, is associated with an increased risk of atrial fibrillation and ischemic stroke in older adults, a large community-based study published in JAMA Cardiology has revealed. The findings are from the Atherosclerosis Risk in Communities Study and were reported by Mats C. H. Lassen of the Cardiovascular Division at Brigham and Women’s Hospital and colleagues.
Primary aldosteronism has traditionally been viewed as a distinct and often underdiagnosed cause of secondary hypertension. However, growing evidence suggests that renin-independent aldosterone excess may exist along a continuum, even among individuals without overt disease. Whether this broader hormonal spectrum translates into higher cardiovascular risk has remained uncertain.
To explore this question, investigators conducted a prospective cohort analysis of 3,477 community-dwelling older adults enrolled in the ARIC study. Participants were free of heart failure, myocardial infarction, stroke, and potassium-sparing diuretic use at baseline (2011–2013), when serum aldosterone and renin levels were measured. The mean age was approximately 75 years, and 61.5% were women. The median aldosterone level was 5.1 ng/dL, renin activity was 0.78 ng/mL per hour, and the median ARR was 5.9.
Participants were followed for a median of nine years. Using Cox regression models, the researchers assessed associations between aldosterone measures and incident cardiovascular outcomes, including heart failure hospitalization, atrial fibrillation, ischemic stroke, myocardial infarction, and a composite endpoint that also included all-cause mortality.
Key Findings:
- A higher aldosterone-renin ratio was independently associated with an increased risk of the composite cardiovascular outcome.
- The elevated risk was primarily driven by higher rates of atrial fibrillation and ischemic stroke.
- Each doubling of ARR was associated with a 10% increased risk of atrial fibrillation.
- Each doubling of ARR was associated with a 13% increased risk of ischemic stroke.
- No significant association was found between ARR and incident heart failure hospitalization.
- No significant association was observed between ARR and myocardial infarction.
The findings suggest that dysregulated aldosterone activity, even below the threshold of clinically recognized primary aldosteronism, may contribute to arrhythmia and cerebrovascular risk in older adults. These results point to aldosterone signaling pathways as potential targets for cardiovascular prevention strategies.
The authors noted key limitations. Aldosterone and renin were measured only once, without controlling for sodium intake, timing, or medications. Dietary sodium data and repeat hormone measurements were unavailable. As participants were older and free of CVD at baseline, survival bias is possible. Multiple comparisons were also conducted without adjustment, increasing the risk of chance findings.
Despite these caveats, the study provides one of the most comprehensive evaluations to date of aldosterone dysregulation and cardiovascular outcomes in a community-based elderly population. The authors conclude that the spectrum of primary aldosteronism has clinically meaningful implications, particularly for atrial fibrillation and stroke risk, and may warrant broader consideration in cardiovascular risk assessment and prevention.
Reference:
Lassen MCH, Ostrominski JW, Claggett BL, et al. Spectrum of Primary Aldosteronism and Risk of Cardiovascular Outcomes: The Atherosclerosis Risk in Communities Study. JAMA Cardiol. Published online March 04, 2026. doi:10.1001/jamacardio.2026.0068
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