Why were the 2023 Guidelines of the European Society of Hypertension not developed as Joint Guidelines together with the European Society of Cardiology?

The guidelines for the management of arterial hypertension of the European Society of Hypertension (ESH) were developed for the first time in 2003 [1]. At that time, ESH offered to share these hypertension guidelines as joint guidelines with the European Society of Cardiology (ESC), which accepted after the manuscript had already been completed, without sharing its publication in the ESC Society Journal. Thus, the 2003 Joint guidelines were published in the ESH Journal only [1]. Subsequently, the ESH and the ESC enjoyed an equal collaboration, resulting in three further successful and widely quoted guidelines in 2007 [2], 2013 [3] and 2018 [4] that were published in the official journals of both Societies, except for a 2009 reappraisal of the 2007 guidelines, which was prompted by new evidence in the hypertension area and prepared and published only by the ESH [5].

At the time of the preparation of the 2018 joint ESC/ESH guidelines, ESH and ESC renewed their agreement on future hypertension guidelines that detailed all aspects of the collaboration, including equal representation in the writing task force, alternation of the chairman’s nomination, equal contribution to the expenses, simultaneous publication of the guidelines in the two society journals and guidelines presentation at the annual society meetings.

In October 14, 2021, the acting president of the ESH and the ESH Co-Chair of the 2018 joint ESC/ESH guidelines wrote an invitation letter on behalf of the ESH Council to the acting President of the ESC . In this letter ESH mentioned “following our successful collaboration with ESC in previous years including the generation of the current 2018 ESC/ESH Guidelines we are looking forward to continue our work together with the ESC Task Force on this topic. ESH recently organized a two day meeting entirely dedicated to the discussion on the development of the future European hypertension guidelines. Several members of the ESC Council on Hypertension, including the Chair, participated in this meeting. We discussed and identified several aspects that would already require an update in the next Guidelines. Based on the fact, that the planning and final production of the news Guidelines will require a long lead-time, we are contacting you today to ask you about your opinion and suggestion as we may proceed from the ESC point of view”.

After almost 3 months, i.e. on January 5, 2022, the ESC President responded to this letter stating the following “ESC would like to invite the ESH to develop the next guideline for the management of arterial hypertension ‘in collaboration’ (rather than jointly, as it was labelled in the past). The document, which would be titled ‘ESC Guidelines for the management of arterial hypertension developed in collaboration with the ESH’, would follow the ESC rules for Guideline development and timelines in order to be published in 2024, during the ESC Congress. ESH will be asked to nominate a number of official ESH representatives to join the Task Force, who must meet ESC participation requirements. ESH will be granted co-publication rights of the guideline document in the ESH journal.”

In two subsequent letters sent to the ESC on January 21 and March 15 in 2022, the ESH expressed its disagreement with the procedure as proposed by ESC. ESH mentioned that “The European Hypertension guidelines were originally initiated by ESH in 2003 and developed without ESC involvement. Only after completion of the guidelines and at the invitation of ESH, ESC accepted to be involved but without ESC-nominated members in the writing committee and without publication in the European Heart Journal, which only started in 2007.”

ESH suggested to continue the development of joint guidelines according to the agreement between ESC and ESH issued in 2016, which contains the following essential aspects:

• Common development of ESC/ESH and ESH/ESC guidelines in alternating order and not unidirectional ESC guidelines in collaboration with ESH.

• Independent selection of participating ESH authors by the ESH according to the ESH rules.

• Presentation of the guidelines both during the ESC and during the ESH annual congress in 2024.

ESH also expressed the hope that a “mutually satisfactory agreement” could be achieved. “In this way, we could avoid that ESH is forced to return to its original approach of developing independent European guidelines.”

In their final response to the above letters, ESC represented by the acting ESC President and Chair of the Clinical Practice Guidelines Committee allowed ESH to have a ‘preview’ presentation of the guidelines during the ESH annual congress in 2024. However, ESC insisted as per the ESC Board decision, that the guidelines will be developed by the ESC “in collaboration with ESH.” Furthermore, this time it was stated that “the ESH will be represented by three Task Force members and three reviewers. Participating ESH authors and reviewers can be appointed by the ESH but must comply with ESC DOI and participation rules.”

Taken together, all attempts by ESH to modify the ESC position and to reestablish the original written agreement in correspondence and by verbal contacts with ESC officers were fruitless.

Consequently, the ESH Council after careful consideration in several meetings decided to stop the collaboration with the ESC on future guidelines and to count for their future preparation exclusively on ESH available expertise and forces. The 2023 ESH guidelines for the management of arterial hypertension were subsequently developed by a Task Force of 59 European hypertension experts including several members of the ESC Council on hypertension and the ESC Chairman of the 2018 ESC/ESH guidelines [6]. Importantly, the 2023 ESH guidelines were endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA).

This team effort of European experts generated a comprehensive synthesis on the current evidence for the management of hypertension. Future implementation strategies can build on this document and hopefully contribute to better blood pressure control and management of hypertensive patients, and thus reduce cardiorenal and vascular morbidity and mortality.

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Funding

The author(s) reported there is no funding associated with the work featured in this article.