Baxdrostat: A First-in-Class Aldosterone Synthase Inhibitor for Resistant Hypertension

Hypertension remains the world's leading preventable cause of cardiovascular morbidity and mortality. Despite the availability of diverse antihypertensive drug classes, resistant hypertension continues to affect millions globally, leading to a disproportionate risk of stroke, heart failure, kidney disease, and premature death. Aldosterone excess is a central driver of treatment resistance, yet direct pharmacological suppression of aldosterone biosynthesis has long eluded clinical success due to the challenge of selectively targeting aldosterone synthase (CYP11B2) over its near-identical paralog 11β-hydroxylase (CYP11B1). Baxdrostat (CIN-107, RO6836191), an orally bioavailable, highly selective aldosterone synthase inhibitor (ASI), has now demonstrated robust blood pressure reduction in phase 3 clinical trials, marking a potential paradigm shift in the management of resistant hypertension. This Review summarizes the pathophysiology of aldosterone in hypertension, the molecular pharmacology of CYP11B2 inhibition, the discovery and development of Baxdrostat, and its clinical evaluation. We further discuss the broader implications of targeting steroidogenic cytochrome P450 enzymes and highlight future opportunities and challenges as Baxdrostat and related agents enter the cardiovascular pharmacopeia.