Natriuretic peptides and cardiac troponins in hypertension and heart failure: A contemporary review of the evidence

Hypertension is the second leading cause of heart failure (HF), yet strategies for identifying hypertensive individuals at increased HF risk remain limited. Cardiac biomarkers, particularly natriuretic peptides and cardiac troponins, reflect subclinical myocardial stress and injury, and have emerged as promising tools for refining HF risk stratification in hypertensive populations. Experimental, epidemiological, and post-hoc analyses of interventional studies have consistently demonstrated that elevated concentrations of these biomarkers are independently associated with blood pressure elevation and variability, abnormal circadian patterns, progression to hypertension, and increased risk of HF and other major cardiovascular events. Both biomarker classes correlate with left ventricular hypertrophy, diastolic dysfunction, and myocardial fibrosis, and their concentrations decline with effective antihypertensive therapy, supporting their use in monitoring treatment response. Incorporating these biomarkers into conventional risk prediction models improves discrimination, and post-hoc analyses of large trials such as the SPRINT suggest greater absolute benefit of intensive blood pressure lowering among biomarker-positive individuals. Despite this robust evidence base, major hypertension guidelines have not explicitly integrated biomarker testing into routine care. This narrative review aims to summarize current evidence on the mechanistic, prognostic, and therapeutic value of natriuretic peptides and cardiac troponins in hypertension and outlines key research priorities, including pragmatic randomized trials of biomarker-guided prevention strategies, cost-effectiveness analyses, integration with multi-omics and artificial intelligence for precision phenotyping, and development of simplified screening approaches for resource-limited settings. Embedding cardiac biomarker assessment into hypertension care pathways could enable earlier detection, more personalized blood pressure management, and ultimately reduce the burden of HF worldwide. This figure illustrates the key roles of natriuretic peptides and cardiac troponins in hypertension, including their associations with BP dynamics (elevation, variability, circadian pattern, and incident hypertension), cardiac remodeling reflecting underlying pathophysiological processes, cardiovascular risk stratification, and their potential to guide personalized BP management. BP blood pressure; LVH left ventricular hypertrophy; LA left atrial; HF heart failure; CVD cardiovascular disease.