Plasma renin activity, response to aliskiren, and clinical outcomes in patients hospitalized for heart failure: the ASTRONAUT trial

Muthiah Vaduganathan, Baljash Cheema, Erin Cleveland, Kamya Sankar, Haris Subacius, Gregg C. Fonarow, Scott D. Solomon, Eldrin F. Lewis, Stephen J. Greene, Aldo P. Maggioni, Michael Böhm, Faiez Zannad, Javed Butler*, Mihai Gheorghiade

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

22 Scopus citations


Aims: The direct renin inhibitor, aliskiren, is known to reduce plasma renin activity (PRA), but whether the efficacy of aliskiren varies based on an individual's baseline PRA in patients hospitalized for heart failure (HF) is presently unknown. We characterized the prognostic value of PRA and determined if this risk is modifiable with use of aliskiren. Methods and results: This pre-specified neurohormonal substudy of ASTRONAUT analysed all patients hospitalized for HF with ejection fraction (EF) ≤40% with available baseline PRA data (n = 1306, 80.9%). Risk associated with baseline PRA and short-term changes in PRA from baseline to 1 month was modelled with respect to 12-month clinical events. Median baseline PRA was 3.0 (interquartile range 0.6–16.4) ng/mL/h. Aliskiren significantly reduced PRA early after treatment initiation through 12-month follow-up compared with placebo (P < 0.001). The lowest baseline PRA quartile (<0.6 ng/mL/h) was independently predictive of lower all-cause mortality [adjusted hazard ratio (HR) 0.50, 95% confidence interval (CI) 0.31–0.81] and the composite of cardiovascular mortality and HF hospitalization (adjusted HR 0.57, 95% CI 0.40–0.79). Delta log-normalized PRA (from baseline to 1 month) was not predictive of either primary endpoint at 12 months (P ≥ 0.43). The prognostic value of baseline PRA and short-term changes in PRA did not vary by randomization to aliskiren or placebo (interaction P ≥ 0.13). Conclusions: Plasma renin activity is reduced early and durably by aliskiren, but this did not translate into improved clinical outcomes in ASTRONAUT. Baseline PRA or short-term reduction in PRA do not identify a subgroup who may preferentially benefit from direct renin inhibition. Clinical Trial Registration Unique Identifier: NCT00894387.

Original languageEnglish (US)
Pages (from-to)677-686
Number of pages10
JournalEuropean Journal of Heart Failure
Issue number4
StatePublished - Apr 2018


  • Clinical outcomes
  • Heart failure
  • Neurohormones
  • Renin

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine


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