Angiotensinogen Reconsidered: Evolving Perspectives in Hypertension Research

Hypertension is the leading modifiable risk factor for cardiovascular disease, stroke, chronic kidney disease, and premature mortality. Although AGT (angiotensinogen) is a central component of the renin-angiotensin-aldosterone system, it was historically viewed primarily as a biochemical substrate rather than an active regulator of blood pressure and received less attention as a therapeutic target in hypertension compared with downstream renin-angiotensin-aldosterone system components such as angiotensin-converting enzyme and angiotensin II receptors. However, emerging evidence highlights its dynamic, tissue-specific role in blood pressure regulation and its responsiveness to metabolic, hormonal, and inflammatory stimuli. This narrative review examines the molecular biology, structure-function relationships, and regulatory mechanisms of AGT, including genetic variants such as M235T and -6G>A, which contribute to interindividual and population-level susceptibility to hypertension. We further explore AGT's pathogenic role in salt-sensitive hypertension, obesity-related inflammation, and renin-angiotensin-aldosterone system escape phenomena. Recent translational advances, including RNA-based therapeutics such as small interfering RNAs (zilebesiran) and antisense oligonucleotides (tonlamarsen), demonstrate promising blood pressure reductions and favorable safety profiles in clinical trials. AGT also shows potential as a biomarker for hypertensive nephropathy and treatment responsiveness. This review underscores the value of AGT as an upstream therapeutic target and diagnostic marker, offering new avenues for precision medicine and long-acting strategies in the management of both conventional and resistant hypertension while possibly addressing medication adherence-related obstacles.