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REFLECTIONS
Hypertension
Hypertension Global Newsletter #9 2025

2024 ESC guidelines, renal denervation can be considered in patients with resistant hypertension and those with an increased risk of
CVD and uncontrolled hypertension who are receiving fewer than three drugs if they express a preference after a shared discussion
about the risks and benefits. In contrast to the ESH guidelines,
Hypertension
the ESC guidelines emphasise that renal denervation should not
be recommended as a first-line BP-lowering intervention. Both
guidelines do not recommend renal denervation to treat patients
with an estimated glomerular filtration rate (eGFR) of <40 mL/
min/1.73 m2 or secondary hypertension, because these groups
were excluded from the sham-controlled trials.

Despite the fundamental agreement on the definition of
hypertension and most lifestyle recommendations, the 2023 CLICK HERE
ESH and 2024 ESC guidelines present different risk stratification READ A COMMENTARY ON WHETHER
and treatment initiation strategies, particularly for high-risk OR NOT BOTH GUIDELINES ARE
patients who fall below the conventional hypertension threshold. NECESSARY BY AUTHORS ALETTA E.
This comparison allows healthcare professionals to understand SCHUTTE AND GARRY L.R. JENNINGS.
the implications of these differences, and therefore effectively
tailor treatment and management to individual patient profiles,
improving CVD prevention and patient outcomes.
CLICK HERE
FOR THE LINK TO FULL ARTICLE

Development of the European Society of Hypertension guidelines for the
management of arterial hypertension: Comparison of the helpfulness of ESH 2013,

2018, and 2023 guidelines.
Koller A, et al. J Hypertens. 2025 Feb;43(5):852-858.

The development and refinement of clinical practice guidelines for the management of arterial hypertension are a critical area of
medical interest. They serve as an essential tool for guiding physicians and patients in preventing or mitigating the consequences
of high BP. Over the past 20 years, the ESH has published major revisions to its guidelines in 2013, 2018, and most recently 2023.
However, prior analyses of CV guidelines have consistently shown that they rely on limited high-quality evidence, with studies
indicating that often less than 15% of recommendations are supported by Level A evidence (multiple randomised clinical trials or
meta-analyses).

The primary purpose of this study was to compare the helpfulness of the ESH guidelines across the three editions regarding
the diagnosis and treatment of hypertension. In addition, since there are no systematic methods to quantitatively measure the
helpfulness or quality of guidelines, this study looked to introduce and test a mathematical analysis designed to provide an
objective assessment of a guideline’s helpfulness, allowing for reliable comparisons between either different versions or entirely
different medical guidelines.

A comparative mathematical analysis was conducted across the ESH guidelines from 2013, 2018, and 2023. The traditional
approach of examining only the frequency of Classes of Recommendations (CLASS) and Levels of Evidence (LEVEL) was noted
to lead to biased results. Therefore, the novel method involved calculating the ratio of certainty/uncertainty based on the LEVEL
associated with each CLASS. The authors calculated a newly formulated certainty index (CI), which allows the CLASS and LEVEL
to be assessed together. The CI is intended to complement and not replace the traditional CLASS/LEVEL grading. This CI ranges
from –1 (100% uncertainty) to +1 (100% certainty). Preliminary frequency analysis showed that the number of recommendations
significantly increased from 2013 (N = 110) to 2018 (N = 169) to 2023 (N = 269). The ESH 2023 guideline included approximately
1.5 times more recommendations than the 2013 version.

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