ACC lays out stepwise strategy for resistant hypertension

Clinical takeaway: Before labeling hypertension “resistant,” confirm accurate BP measurement, assess adherence and out-of-office BP, and look for interfering substances and secondary causes. For true resistance, optimize the standard 3-drug regimen and diuretic therapy before adding a mineralocorticoid receptor antagonist (MRA) or considering newer agents or renal denervation.

The 2026 American College of Cardiology Expert Consensus Decision Pathway offers a practical framework for adults with resistant hypertension, defined as BP ≥130/80 mm Hg despite maximally tolerated therapy from at least 3 complementary antihypertensive classes, including a diuretic, or controlled BP requiring at least 4 classes. The pathway operationalizes recommendations from the 2025 AHA/ACC multisociety hypertension guideline rather than replacing them.

The authors emphasize ruling out “pseudoresistance” before escalating treatment. Clinicians should verify measurement technique, use out-of-office monitoring, assess adherence, review prescription drugs, OTC products and supplements that can raise BP, and screen for secondary causes; 24-hour ambulatory monitoring is preferred over home monitoring for confirming resistant hypertension when available.

Drug therapy starts with optimization. Clinicians should favor longer-acting or more potent agents where appropriate and simplify regimens with single-pill combinations; optimization of thiazide/thiazide-like diuretics, including use of chlorthalidone or indapamide, is emphasized.

For a fourth drug, MRAs such as spironolactone or eplerenone have the strongest evidence. Renin and aldosterone should be measured before starting an MRA, while potassium and creatinine should be checked 1 to 2 weeks after initiation or titration and every 3 to 6 months thereafter; MRAs are contraindicated with hyperkalemia or eGFR <30 mL/min/1.73 m².

The pathway also incorporates newer options. Aprocitentan and the aldosterone synthase inhibitor baxdrostat should be considered only for confirmed true resistant hypertension after optimization of a standard 4-drug regimen including an MRA and consultation with a hypertension specialist.

Renal denervation may be considered as an adjunct in carefully selected patients with resistant stage 2 hypertension despite optimal therapy, or those unable to tolerate additional medications. The authors stress shared decision-making because the procedure is not curative, may not reduce medication requirements, and lacks robust long-term cardiovascular outcomes data.

Key Recommendations

• Confirm true resistance with standardized BP technique, out-of-office monitoring, and objective adherence assessment.
• Optimize ACE inhibitor/ARB, long-acting dihydropyridine calcium channel blocker, and thiazide/thiazide-like diuretic therapy before adding drugs. Use an MRA as the preferred fourth-line agent when not contraindicated.
• Reserve aprocitentan, baxdrostat, and renal denervation for persistent true resistant hypertension after optimized standard therapy and specialist input.
• Intensify lifestyle treatment, particularly sodium restriction, weight management, exercise, and potassium-rich dietary strategies when safe.

Source: Davis LL, et al. (2026 Oct 5) J Am Coll Cardiol. Optimizing Blood Pressure Care in Patients With Resistant Hypertension: 2026 ACC Expert Consensus Decision Pathway