Revisiting Urine Albumin-Creatinine Ratio in Cardiovascular Risk Assessment
Overview
Longitudinal trajectories of urine albumin-to-creatinine ratio (UACR) over 5 and 10 years are strongly associated with increased risks of heart failure, atrial fibrillation, and coronary heart disease. High-risk UACR trajectories identify individuals at elevated cardiovascular risk beyond baseline UACR levels, including those with initially normal values.
Background
Albuminuria, defined as urinary albumin excretion ≥30 mg/day, is a recognized marker of cardiovascular and kidney disease, reflecting systemic endothelial dysfunction and microvascular injury. Single spot urine protein measurements are limited by variability, but the urine albumin-to-creatinine ratio (UACR) overcomes these by adjusting for urine concentration. UACR is incorporated into cardiovascular risk prediction models and recent guidelines for hypertension screening, highlighting its clinical relevance.
Data Highlights
UACR Trajectory
Risk Increase for HF (%)
Risk Increase for AF (%)
Risk Increase for CHD (%)
5-year sustained medium to high
145
77
53
10-year rapid rise
191
87
19
Key Findings
Three distinct UACR trajectories were identified over 5 and 10 years: slow rise at low level, slow rise at medium level, and either sustained medium to high or rapid rise.
High-risk trajectories (sustained medium to high and rapid rise) were associated with 90–191% increased risk of heart failure and 19–87% increased risk of atrial fibrillation and coronary heart disease.
Associations between UACR trajectories and cardiovascular outcomes were largely independent of baseline UACR, indicating the value of serial measurements.
Individuals with normal baseline UACR but high-risk trajectories had significantly worse outcomes, underscoring the limitations of single measurements.
High-risk UACR trajectories correlated with elevated biomarkers of myocardial injury and stress, including NT-proBNP, hs-TnT, and interstitial myocardial fibrosis.
High-risk trajectories were more prevalent among males, non-White individuals, smokers, and those with diabetes, obesity, higher blood pressure, or higher baseline UACR.
Clinical Implications
Routine serial measurement of UACR in clinical practice can enhance cardiovascular risk stratification beyond single-time-point assessments, enabling earlier identification of high-risk individuals. Given that albuminuria is modifiable with therapies such as renin–angiotensin–aldosterone system blockade, incorporating UACR trajectories may guide preventive interventions and improve outcomes.
Conclusion
Longitudinal assessment of UACR trajectories provides valuable prognostic information for cardiovascular disease risk beyond baseline measurements, supporting its integration into routine cardiovascular risk evaluation and management.
