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REFLECTIONS
Hypertension
Hypertension Global Newsletter #9 2025

The ratio of certainty/uncertainty in the ESH 2013, 2018, and 2023 guidelines Hypertension

The certainty index in the ESH guidelines

C, certainty; UC, uncertainty.

The mathematical analysis demonstrated continuous and significant improvements in certainty across the guidelines when using the
novel CI method. The analysis showed a continuous improvement in the percentage of certainty from 2013 to 2023: 60.5% in 2013,
72.1% in 2018, and 75.3% in 2023. Correspondingly, the CI also significantly increased across the years, moving from 0.21 to 0.44 to
0.51. Importantly, these metrics contrast with potentially misleading frequency-based interpretations. For example, the proportion of
Level A evidence decreased from 42.0% in 2018 to 22.7% in 2023; however, the CI shows that overall certainty still improved.

The ESH 2023 guidelines have 94 recommendations, almost The certainty index of recommendations in
half of which are new, for the prevention of hypertension- established CVDs in the ESH 2023
related CVDs as well as for the treatment of hypertension
complicated by these diseases and other diseases that
significantly increase CV risk. Among the examined CVDs,
valvular heart disease and cerebrovascular disease showed
the lowest CI with a certainty of 18.75% and 25%, respectively.
The highest CI was found in the case of coronary artery
disease and heart failure with a certainty of 75%, such as in
diabetes. CI in pregnancy represented a certainty of 68.8%,
and in kidney disease, it was 62.5%

The analysis confirmed that the ESH 2023 guideline structure
was rearranged and simplified, enhancing readability
and clinician usability. The increase in the number of
recommendations also reflects a growing understanding of
hypertension epidemiology, mechanisms, and clinical findings.
The continuous improvement of these guidelines provides
clinicians with a more certain and detailed guide. The authors
suggest further improving guidelines by focusing on individual
characteristics (e.g., age, gender, genetics). Additionally, GL, guideline.

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