Baxdrostat in Resistant and Uncontrolled Hypertension: A Systematic Review and Meta-Analysis.

Abstract

Background: Aldosterone dysregulation is becoming more widely acknowledged as a key factor in resistant hypertension. Baxdrostat, a highly selective aldosterone synthase inhibitor that shows a 100:1 preference for CYP11B2 over CYP11B1, has been tested in various randomized controlled trials involving different hypertensive groups. We carried out a systematic review and meta-analysis to assess the efficacy and safety of baxdrostat for treating resistant hypertension.

Methods: We included randomized, double-blind, placebo-controlled trials of baxdrostat in adults with hypertension from inception through March 2026. The primary outcome was the placebo-corrected change in seated systolic blood pressure (SBP). Secondary outcomes included the change in diastolic blood pressure (DBP), the proportion of patients achieving seated SBP < 130 mmHg, and the incidence of hyperkalemia and other adverse events.

Results: Five trials (N = 1,730) were included: BrigHTN, HALO, BaxHTN, FigHTN, and Bax24. Baxdrostat significantly reduced seated SBP vs. placebo (MD -6.90 mmHg; 95% CI, -10.25 to -3.55; P < 0.0001), with high heterogeneity (I² = 74%). Numerically larger reductions were observed at higher doses: the 2 mg dose yielded the largest reduction (MD -8.16 mmHg; P < 0.00001; I² = 45%), followed by 1 mg (MD -6.06 mmHg; P = 0.010), while 0.5 mg was non-significant (P = 0.14). Baxdrostat increased the odds of achieving SBP < 130 mmHg (OR 2.70; P = 0.01), although the magnitude of this effect varied substantially across trials (I² = 89%). DBP reduction was significant at the 2 mg dose (MD -3.51 mmHg; P < 0.0001) and the 1 mg dose (MD -2.55 mmHg; P = 0.03). Safety analysis showed higher odds of hyperkalemia (8.9% vs. 1.2%; OR 5.98; P = 0.008), with potassium > 6.0 mmol/L in 3.8% of baxdrostat-treated patients versus 0.2% with placebo. Serious adverse events were not significantly increased (OR 1.35; P = 0.37). No deaths were attributable to baxdrostat.

Conclusions: Baxdrostat produces statistically significant reductions in systolic blood pressure among various hypertensive populations, increasing the likelihood of achieving blood pressure targets (SBP < 130 mmHg), although the magnitude of this effect varied substantially across trials (I² = 89%). Hyperkalemia was the principal safety concern but was not associated with serious clinical sequelae in the included trials. These findings support further investigation of aldosterone synthase inhibition as a therapeutic strategy for resistant and uncontrolled hypertension, with definitive clinical positioning awaiting results from ongoing cardiovascular and renal outcomes trials.