The conservative–challenging paradigm of antihypertensive therapy in JSH2025: a comparative perspective with contemporary Western guidelines

Q: What is the clinical evidence from this study?

Study design: null. Population: hypertension. Intervention: antihypertensive therapy vs. Western guidelines. Primary outcome: achieving target BP (null, 95% CI null, p=null).

Hisashi Kai

doi:10.1038/s41440-025-02545-w

January 9, 2026Hypertension ResearchOpen Access

The conservative–challenging paradigm of antihypertensive therapy in JSH2025: a comparative perspective with contemporary Western guidelines

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Key result

JSH2025 adopts a conservative yet challenging paradigm for hypertension management, emphasizing initial monotherapy and structured intensification.

Key Points

To review the unique conservative-challenging therapeutic framework of the JSH2025 hypertension guidelines in comparison with contemporary Western guidelines.
Analyzed therapeutic recommendations from the JSH2025 guidelines alongside Western guidelines including ESH2023, ESC2024, and AHA/ACC2025.
Evaluated Japanese clinical factors including high salt sensitivity, insurance limitations on initial single-pill combinations, and access to unique antihypertensive agents.
JSH2025 defines blood pressure targets as <130/80 mmHg (<125/75 mmHg for home blood pressure), recommending achievement within up to six months generally and one to three months for high-risk patients.
Initial monotherapy (Step 1) is retained, while Step 2 combination therapy is advised when goals are unmet since fewer than 40% of patients achieve blood pressure targets on monotherapy alone.
Group 2 agents, including sacubitril/valsartan and esaxerenone, are endorsed from Step 2 onward, providing additional systolic blood pressure reductions of up to ~15 mmHg and improved 24-hour control.

Study Design

Type

null

Blinding

null

Randomization

null

Structured PICO

P

Population

Adults with hypertension, particularly focusing on the Japanese population characterized by high salt intake, salt sensitivity, and increasing prevalence of obesity, diabetes, and chronic kidney disease.

I

Intervention

JSH2025 guideline-directed antihypertensive therapy (conservative monotherapy initiation followed by structured stepwise intensification, including the use of novel agents like sacubitril/valsartan and esaxerenone).

C

Comparator

Contemporary Western guidelines (ESH2023, ESC2024, AHA/ACC2025) which recommend initial dual combination therapy.

Main Result

Effect estimate: null (95% CI null)

p-value: p=null

Limitations

Concerns regarding safety and tolerability in high-risk patients
Limited evidence from large-scale randomized controlled trials comparing monotherapy and combination therapy

Implication

The JSH2025 guidelines present a unique paradigm for hypertension management in Japan, contrasting with Western guidelines by maintaining a monotherapy-first approach while integrating novel agents like sacubitril/valsartan and esaxerenone in early stepwise intensification.

Abstract

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Discussion

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Cite This Study

Hisashi Kai (2026) conducted a null in hypertension. antihypertensive therapy vs. Western guidelines was evaluated on achieving target BP (null, 95% CI null, p=null). JSH2025 adopts a conservative yet challenging paradigm for hypertension management, emphasizing initial monotherapy and structured intensification.

synapsesocial.com/papers/696321b391e05aa366cb7eed https://doi.org/10.1038/s41440-025-02545-w

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The conservative–challenging paradigm of antihypertensive therapy in JSH2025: a comparative perspective with contemporary Western guidelines

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

The conservative–challenging paradigm of antihypertensive therapy in JSH2025: a comparative perspective with contemporary Western guidelines

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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