ACC 2026 Expert Consensus Decision Pathway Outlines Stepwise Approach to Resistant Hypertension

The American College of Cardiology (ACC) has issued a 2026 Expert Consensus Decision Pathway (ECDP) on optimizing blood pressure (BP) care in adults with resistant hypertension, published in the Journal of the American College of Cardiology. The document operationalizes the 2025 American Heart Association/ACC/Multisociety High Blood Pressure Guideline through a 5-question framework.

Apparent treatment-resistant hypertension affects an estimated 8.5% to 20% of US adults with hypertension, the authors noted. The ECDP defines resistant hypertension as uncontrolled BP (systolic BP [SBP] ≥130 mm Hg or diastolic BP [DBP] ≥80 mm Hg) despite at least 3 maximally tolerated antihypertensive classes, including a diuretic, or controlled BP on 4 or more classes. Before confirming true resistance, the authors call for objective adherence assessment, citing a meta-analysis of 42 studies that found a pooled nonadherence prevalence of 37% among patients with apparent resistant hypertension.

The pathway describes first optimizing the 3-drug regimen, for example, with longer-acting agents and single-pill combinations. Among fourth- and fifth-line agents, mineralocorticoid receptor antagonists (MRAs) have the best evidence, the authors wrote, although the supporting PATHWAY-2 trial enrolled a predominantly non-Hispanic White cohort.

According to the ECDP, newly approved aprocitentan, a dual endothelin receptor antagonist, and baxdrostat, an aldosterone synthase inhibitor, should be considered only for confirmed true resistant hypertension after optimizing a 4-drug regimen including an MRA and consulting a hypertension specialist. The authors listed high cost and limited long-term cardiovascular outcome data among key limitations. Renal denervation (RDN) may be considered as an adjunct in carefully selected patients with resistant hypertension despite optimal medical therapy or intolerable adverse effects from additional agents who have an office SBP of 140 to 180 mm Hg, DBP ≥90 mm Hg, and an estimated glomerular filtration rate ≥40 mL/min/1.73 m².

The authors noted that long-term hard cardiovascular outcome data for RDN are limited and that cuffless BP devices currently lack sufficient validation for routine clinical use.

Source: Davis LL, Yang E, Blyler CA, et al. Optimizing blood pressure care in patients with resistant hypertension: 2026 ACC Expert Consensus Decision Pathway: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Published online October 5, 2026. doi:10.1016/j.jacc.2026.08.028