ACR Appropriateness Criteria® Renovascular Hypertension: Update 2026

Renovascular hypertension is the most common cause of secondary hypertension and occurs in 0.5% to 5% of individuals with hypertension. This is more common in individuals who have difficulty controlling their pressure or elderly patients with end-stage kidney disease. An evaluation for renovascular hypertension is indicated if there is a high level of clinical suspicion. The primary imaging modalities for assessing renovascular hypertension are ultrasound, CT, and MRI, and these options can vary depending on the patient's current renal status. Although ultrasound is beneficial since it uses nonionizing radiation, CT with contrast provides excellent spatial resolution. In patients with decreased renal function, MRI is a reliable alternative. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.