Genetic and Epigenetic Biomarkers in Hypertension: Impact on the Effectiveness of Individualized Therapy: A Systematic Review

Arterial hypertension (AH) affects over 1.28 billion adults globally, remaining a leading cause of cardiovascular morbidity and mortality. Despite effective therapies, suboptimal blood pressure control persists, highlighting the need for precision approaches. Epigenetic biomarkers, particularly DNA methylation, have emerged as potential tools to enhance risk stratification and personalise antihypertensive therapy, yet their clinical relevance remains uncertain. To systematically synthesise evidence on genetic and epigenetic biomarkers associated with hypertension, focusing on DNA methylation signatures, regulatory pathways, and translational potential. We conducted a systematic review and meta-analysis following PRISMA guidelines, registered in PROSPERO (CRD420251059256). PubMed, MEDLINE, Embase, and ScienceDirect were searched up to March 2025. Eligible studies investigated genetic or epigenetic markers, such as DNA methylation, single nucleotide polymorphisms, or chromatin modifications in adult hypertension populations. Data on study design, populations, biomarkers, analytical methods, and outcomes were extracted. Risk of bias was assessed using RoB 2 and ROBINS-I tools. Twelve studies were included, encompassing cross-sectional and longitudinal designs. DNA methylation signatures at loci including AGTR1, PHGDH, SLC7A11, ACE, and WNT3A were recurrently associated with blood pressure regulation. Trans-ancestry genome-wide analyses identified methylation-enriched loci such as KCNK3, PDE3A, and PRDM6. However, no study demonstrated predictive value for clinical endpoints or robust replication across diverse populations. Methodological heterogeneity limited longitudinal data, and underrepresentation of low- and middle-income countries were key limitations. While epigenetic markers show promise for hypertension research, current evidence remains exploratory. Rigorous, longitudinal studies integrating clinical endpoints are essential for advancing toward clinical translation.