Unmasking a Hidden Driver of Hypertension: Insights from Dr. Florian Rader

In a compelling interview, Florian Rader, MD, of Cedars-Sinai, highlights a paradigm shift in how clinicians understand and treat hypertension. Long considered “essential” and without a known cause in most patients, hypertension is now increasingly linked to a specific culprit: aldosterone dysregulation. Dr. Rader emphasizes that this discovery is especially relevant for patients with resistant or severe hypertension, in whom elevated aldosterone levels may drive both cardiovascular and kidney complications. He calls for greater recognition of this mechanism and points to promising new therapies in development that target aldosterone directly. Dr. Rader offers hope for more tailored, effective treatment strategies that could reduce heart failure, stroke, atrial fibrillation, and chronic kidney disease in this high-risk population.

Transcript:

Cardio Care Today: Can you explain the role of aldosterone in maintaining blood pressure and why its dysregulation is such a critical concern in hypertension management?

Dr. Florian Rader: So it’s very interesting. So we always were taught that most cases of hypertension are what’s called essential. So we typically never found a reason for why blood pressure is elevated. And now, I think in the past couple of decades or so, we realize that more and more often we find that there’s actually some underlying cause. And in a lot of patients, especially those with resistant or more severe hypertension, we find aldosterone dysregulation as a driver of blood pressure increases. So that’s sort of a new approach, and it’s important to understand that because there’s some very specific and tailored therapies for that aldosterone problem.

With approximately 120 million adults in the U.S. affected by uncontrolled hypertension, what are the biggest clinical and public health challenges we currently face in addressing this epidemic?

So hypertension clearly is the number one modifiable cardiovascular risk factor. So controlling blood pressure is absolutely crucial to improve cardiovascular outcomes, to lower mortality, and [to] make people with hypertension live longer. So recognizing that hypertension is important, measuring blood pressure correctly, and then addressing the blood pressure and prescribing appropriate medications to bring blood pressure down to goal, which currently is, in most patients, 130 over 80, is absolutely crucial to improve overall patient outcomes.

What evidence links aldosterone dysregulation to both cardiovascular and renal complications, and how might this influence future diagnostic or treatment strategies?

So there’s a good amount of data now that shows that increased aldosterone production is actually linked with poor kidney and cardiovascular outcomes. Most of the evidence comes from observational studies where we just simply compare patients who do not have primary aldosteronism but elevated blood pressure, to those patients who have elevated blood pressure without primary aldosteronism. And there’s some distinct differences between the two groups. For instance, the rates of heart failure, the rate of ischemic heart disease, the rate of atrial fibrillation, [and] stroke, all is increased when aldosterone is the driving force of elevated blood pressures. And on the same time, kidney outcomes, such as progression of chronic kidney disease, or even the incidence of end-stage renal disease and dialysis is also increased in those patients with primary aldosteronism.

What new approaches or treatments are being explored to target aldosterone dysregulation more effectively?

So there’s a lot of new medication classes currently under investigation. I think the bottom line is we need new approaches, we need some new approaches that, first of all, address this aldosterone dysregulation and increased aldosterone levels in the treatment of hypertension because those therapy options will most likely also reduce other cardiovascular problems. And in general, when it comes to treatment options, anything that can improve adherence because the side effect profile is more benign, or other treatment options that just support good blood pressure and bringing blood pressure down to goal will help patients with hypertension, with or without aldosterone problems.