The 2023 European Society of Hypertension (ESH) Guidelines for the management of arterial hypertension 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) threshold 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 hypertension 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 recommended whenever feasible, but they are not a substitute for office measurements in the management of hypertension, 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 combination therapy to treat hypertension, forget about monotherapy. 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, and a reduced risk of cardiovascular death and hospitalization. Combination therapy as the cornerstone of hypertension control is a step in the right direction that should be immediately accepted by the medical community.

Somewhat surprisingly, beta-blockers have been restored 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 comorbid conditions such as cardiovascular disease. The role of vasodilating beta-blockers is also highlighted favorably in the Guidelines. However, the document falls short in providing 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 populations 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 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.

Despite providing both a comprehensive summary of secondary forms of hypertension and somewhat disconnected lists of risk factors and clinical signs, the Guidelines do not provide a systematic methodology for the diagnosis and treatment of secondary hypertension. Admittedly, secondary hypertension accounts for a relatively small proportion 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 pregnant 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 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. Nonetheless, the Guideline Writing Committee should be congratulated on a consensus document that turns confusion to clarity, complexity to simplicity, and therefore, from encryption 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 1. Mancia G, Kreutz R, Brunström M, Burnier M, Grassi G, Januszewicz A, et al. Authors/Task Force Members. 2023 ESH Guidelines for the management of arterial hypertension the Task Force for the management of arterial hypertension of the European Society of Hypertension Endorsed by the European Renal Association (ERA) and the International 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 hypertension: 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 hypertension of the European Society of Cardiology and the European Society of Hypertension. J Hypertens 2018; 36:1953–2041.