Editorial comment
The latest hypertension guidelines: from encryption
to decryption, finally!
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C. Venkata S. Ram a,b,c
hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 11/22/2023
See original paper on page 1874
T
he 2023 European Society of Hypertension (ESH)
Guidelines for the management of arterial hyperten-
sion were unveiled at the 32nd European meeting
on hypertension and cardiovascular protection, held in
June of this year. These Guidelines are an update from
2018 and are published in this edition of the Journal of
Hypertension [1,2].
Guidelines from international bodies are often complex,
fuzzy, and frequently confusing. In welcome contrast, the
ESH 2023 recommendations are clear, and practitioners will
find this a simple document to integrate into their practice.
While not being sensational or novel, the new Guidelines are
concise, timely, and provide valuable recommendations for
the management of hypertension with global implications.
What has not changed is the blood pressure (BP) thresh-
old for treatment in the general population of at
least140 mmHg SBP and/or 90 mmHg DBP. This is good
news for practitioners who will not have to renegotiate
treatment targets with patients. Interestingly, while hyper-
tension is defined as at least 140/90 mmHg, the treatment
target is 130/80 mmHg or less. Some may feel perplexed by
this apparent paradox and rightly wonder how to manage
patients who have achieved a SBP less than140 mmHg but
remain above target. The Guidelines would benefit from
greater clarity regarding this dilemma.
The Guidelines recommend accurate BP measurement
in the office as the gold standard upon which virtually all
available data on the risk of hypertension and the benefits
of BP-lowering interventions and treatment targets are
derived. Again, this is good news for practitioners who
frequently rely on office BP measurements. Home BP and
ambulatory BP measurements do have specific indications,
can provide useful clinical information, and are recom-
mended whenever feasible, but they are not a substitute
for office measurements in the management of hyperten-
sion, as was suggested in 2018. So, we are back to basics
in 2023.
High marks should also be given to the 2023 Guidelines
for emphasizing the importance of automated office BP
(AOBP) measurements. This recommendation should be
embraced globally – forget about manual measurements, it
is all about AOBP now.
The Guideline’s new mantra in management is combi-
nation therapy to treat hypertension, forget about mono-
therapy. This includes at treatment initiation, as the
Guideline notes initial two-drug combination therapy is
associated with a marked reduction in clinical inertia,
improved long-term treatment adherence and BP control,
2072 www.jhypertension.com
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
and a reduced risk of cardiovascular death and hospitaliza-
tion. Combination therapy as the cornerstone of hyperten-
sion control is a step in the right direction that should be
immediately accepted by the medical community.
Somewhat surprisingly, beta-blockers have been re-
stored as a potential first-line option for the treatment of
hypertension alongside angiotensin-converting enzyme
(ACE) inhibitors, angiotensin receptor blockers (ARBs),
calcium channel blockers, and diuretics. Undoubtedly,
beta-blockers are beneficial in many patients with comor-
bid conditions such as cardiovascular disease. The role of
vasodilating beta-blockers is also highlighted favorably in
the Guidelines. However, the document falls short in pro-
viding new evidence supporting beta-blockers as initial
therapy and does not present outcome data from trials with
new generation beta-blockers in hypertension. This leaves
the reader wondering, why the change? A potential answer
is the Writing Committee has adopted a liberal approach to
the choice of antihypertensives where the primary benefit
of treatment is believed to be gained from the reduction in
BP per se, regardless of how it is achieved. Consistent with
this approach is that the Guidelines also state no preference
regarding thiazide versus thiazide-like diuretics, which is
not necessarily true of guidance from other organizations
with an interest in hypertension.
Rightly, the latest Guidelines discuss hypertension in
older patients in detail. Around the world, many popula-
tions are aging, consequently there are more elderly
patients requiring treatment for hypertension. The attention
paid to this cohort of patients is a strength of the Guidelines.
Unfortunately, the same degree of attention is lacking on
how to approach elevated BP levels in younger patients,
who represent a huge segment of the global population. In
clinical practice, it is common to observe high BP levels in
the young, and these presentations may be more common
in emerging economies. The Guideline does recommend
the use of central BP in young patients with isolated systolic
hypertension, and it acknowledges the urgent need for
Journal of Hypertension 2023, 41:2072–2073
a
University of Texas Southwestern Medical School, Dallas, Texas, USA, bApollo
Medical College and Hospitals, Hyderabad, India and cMacquarie University Medical
School, Sydney, Australia
Correspondence to C. Venkata S. Ram, MD, MACP, FACC, FAHA, UT Southwestern
Medical School: The University of Texas Southwestern Medical, Center Medical
School, Dallas, TX 75235, USA. E-mail: drram_v@apollohospitals.com
J Hypertens 41:2072–2073 Copyright © 2023 Wolters Kluwer Health, Inc. All rights
reserved.
DOI:10.1097/HJH.0000000000003548
Volume 41  Number 12  December 2023

outcome-based randomized controlled trials in young
patients with hypertension, but the challenge of how these
patients should be managed remains. Reassurance and
follow-up will not suffice and recommending that young
patients be managed in the same manner as older patients
seems inadequate. The Guidelines could be more assertive
here, even though there is a lack of evidence.
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Despite providing both a comprehensive summary of
secondary forms of hypertension and somewhat discon-
hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 11/22/2023
nected lists of risk factors and clinical signs, the Guidelines
do not provide a systematic methodology for the diagnosis
and treatment of secondary hypertension. Admittedly, sec-
ondary hypertension accounts for a relatively small propor-
tion of patients requiring treatment; however, practitioners
would benefit from clearer pathways on when to suspect
secondary hypertension and how it should be diagnosed
and treated. Sleep apnea in particular merits more detailed
discussion, as do several other potential underlying causes.
The pathophysiology of hypertension in pregnancy is
described nicely in the Guidelines. But other than telling
practitioners what not to do, that is, avoid ACE inhibitors
and ARBs and consider diuretics cautiously, there is no
clarity provided on how to control hypertension in preg-
nant women, thus the confusion continues.
One would have expected the Guidelines to elevate the
role of devise-based therapy such as renal denervation
(RDN). The 2018 Guideline left this question open, and
the 2023 edition largely maintains the status quo, although
RDN is listed as a potential last-line option in patients with
true resistant hypertension and an estimated glomerular
filtration rate (eGFR) greater than 40 ml/min per 1.73 m2.
Given the recent favorable clinical trial data and vast
registry data, a few convincing lines as to who is likely
Journal of Hypertension
Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
The latest ESH hypertension guidelines
to benefit from RDN would have been appropriate as the
procedure is now approved in some countries.
Overall, it is mission accomplished for the 2023 ESH
Guidelines as dissemination will undoubtedly improve
global public health via the early diagnosis and effective
control of hypertension at the community level. Areas
requiring clarity remain and future data from clinical trials
is likely to elucidate these issues in coming years. Nonethe-
less, the Guideline Writing Committee should be congratu-
lated on a consensus document that turns confusion to
clarity, complexity to simplicity, and therefore, from en-
cryption to decryption, finally!
ACKNOWLEDGEMENTS
C.V.S.R. thanks Mr Mark Caswell for his skilled editorial
assistance and for verifying the referencing sources.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
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et al., Authors/Task Force Members. 2023 ESH Guidelines for the
management of arterial hypertension the Task Force for the manage-
ment of arterial hypertension of the European Society of Hypertension
Endorsed by the European Renal Association (ERA) and the Interna-
tional Society of Hypertension (ISH). J Hypertens 2023; 41:1874–2071.
2. Williams B, Mancia G, Spiering W, Agabiti Rosei E, Azizi M, Burnier M,
et al. 2018 ESC/ESH Guidelines for the management of arterial hyper-
tension: the Task Force for the management of arterial hypertension of
the European Society of Cardiology and the European Society of
Hypertension: the Task Force for the management of arterial hyperten-
sion of the European Society of Cardiology and the European Society of
Hypertension. J Hypertens 2018; 36:1953–2041.
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