Renin-to-Aldosterone Ratio Is Mechanistically Associated With Ambulatory Blood Pressure Levels and Control in Treated Hypertensive Patients With Overweight or Obesity

Objective: Combination therapy with a renin–angiotensin system inhibitor (RASi) and a thiazide/thiazide-like diuretic (TZD) or a calcium channel blocker (CCB) is the first-line approach in hypertension management and modulates circulating markers of the RAAS. Since excess adiposity, through different mechanisms, may induce RAAS dysregulation and contribute to blood pressure variability and treatment resistance, this study aimed to evaluate the association between the renin-to-aldosterone ratio (RAR) and ambulatory blood pressure (ABP) in treated hypertensive patients with central overweight (OW) or obesity (OB). Design and method: In a cross-sectional design, 97 adults with essential hypertension and OW/OB on stable RASi + TZD and/or CCB therapy were matched with 97 normal-weight hypertensive controls. All participants underwent 24-hour ABP monitoring and orthostatic direct renin concentration (DRC) and plasma aldosterone concentration (PAC) measurements. Results: RAR and DRC were inversely associated with 24-hour, daytime, and night-time BP in controls but not in OW/OB patients; however, higher RAR and DRC values were linked to greater odds of achieving ABP control across all subgroups, whereas PAC showed no significant associations.Conclusions: RAR, primarily driven by higher DRC levels secondary to the pharmacologic response to RAS inhibition, may reflect a mechanism-based association with ABP control in treated hypertension regardless of BMI.