guidelines for the management of arterial hypertension of the European Society of Hypertension, for the first time ever, it has come to our attention that cirrhosis was briefly mentioned in a table, with a recommendation to preferentially use beta-blockers to treat hypertension in these patients [6]. The authors did not elaborate on this point in the text, but we believe that the simple mention of cirrhosis in the guidelines is already a huge milestone. The rationale behind this is not clear because there is no explanation about the need to choose a nonselective beta blocker (NSBB) to treat both portal hypertension and arterial hypertension with the same medication, but we assumed that is the intention of the authors, as it is well known that portal and arterial hypertension can coexist. In fact, portal hypertension is not significantly different in patients with cirrhosis with and without arterial hypertension [2].Hypertension guidelines have been simplified, conveying the message that blood pressure control is more important than the specific drug class chosen to do so. However, in the case of patients with cirrhosis, the agent may be extremely important because, as we said, NSBB have the potential to modify the natural history of chronic liver disease. NSBB were previously recommended for the sole purpose of preventing bleeding or rebleeding; however, the PREDESCI trial demonstrated that NSBBs could increase decompensation-free survival in patients with cirrhosis and clinically significant portal hypertension [7]. In addition, we now know that carvedilol, which has alpha 1-blocking activity in addition to beta blockade, has not only the greatest effect on reducing portal pressure but also the most potent systemic hypotensive effect [8]. Therefore, carvedilol is an ideal agent for the treatment of arterial hypertension in patients with cirrhosis. In contrast, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can cause hypotension and kidney injury in patients with ascites and should be avoided [9].Guidelines regarding cirrhosis and portal hypertension are not disseminated as successfully among general practitioners as those regarding arterial hypertension, and we believe that the sole mention of cirrhosis in these guidelines will indirectly impact the care of patients with cirrhosis. We would like to congratulate the authors on this, and we hope that this will encourage other societies to dedicate at least one paragraph on their guidelines to address why carvedilol should be the first-line treatment for hypertension in selected patients with cirrhosis. In our view, the first-line treatment for hypertension in patients with cirrhosis should be NSBBs, preferably carvedilol, in the following three scenarios: patients with compensated cirrhosis and clinically significant portal hypertension; patients with decompensated cirrhosis with esophageal varices and no previous variceal hemorrhage; and patients with previous variceal hemorrhage as part of the standard of care for secondary prophylaxi...
