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 Table of Contents  
REVIEW ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 1  |  Page : 15-18

The eighth joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (joint national committee-8) report: Matters arising


Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria

Date of Web Publication10-Mar-2017

Correspondence Address:
Ogba Joseph Ukpabi
Department of Internal Medicine, Federal Medical Center, Umuahia, Abia State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0189-7969.201909

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  Abstract 

America's Joint National Committee (JNC) on the prevention, detection, evaluation, and treatment of high blood pressure is one of the foremost regional regulatory bodies on the management of hypertension. Its latest report (JNC-8) of 2014 has attracted a lot of strong criticisms. The aim of this review is to offer a summarized insight into the different opinions that have trailed its process and content since its publication.

Keywords: Hypertension guidelines, Joint National Committee-7, Joint National Committee-8, matters arising


How to cite this article:
Ukpabi OJ, Ewelike ID. The eighth joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (joint national committee-8) report: Matters arising. Nig J Cardiol 2017;14:15-8

How to cite this URL:
Ukpabi OJ, Ewelike ID. The eighth joint national committee on the prevention, detection, evaluation, and treatment of high blood pressure (joint national committee-8) report: Matters arising. Nig J Cardiol [serial online] 2017 [cited 2017 Jun 25];14:15-8. Available from: http://www.nigjcardiol.org/text.asp?2017/14/1/15/201909


  Introduction Top


Worldwide, 7.6 million premature deaths (about 13.5% of the total) and 92 million disability-adjusted life years – 60% of the global total – were attributed to high blood pressure (BP) in 2001.[1] Hypertension affects 65 million Americans.[2] The United States (US) between 1999 and 2004 had an overall prevalence of 29.3%,[3] and between 2001 and 2011 in Nigeria, it is put at 22.5%.[4] Control of hypertension is even more important in Nigeria considering that about 80% of the attributable burden occurred in low-income and middle-income economies and over half occurred in people aged 45–69 years.[1] Most of the disease burden caused by high BP is borne by low-income and middle-income countries, by people in middle age, and by people with prehypertension.[1] According to the World Health Organization (WHO), Nigeria is considered a middle-income economy.[5]

At the global level, the WHO and International Society of Hypertension (ISH) regulate the management of hypertension and recommend guidelines. The WHO and ISH expect Regional and National Societies to adapt and evolve suitable guidelines based on evidence from local studies as well as peculiar regional and national circumstances. America's Joint National Committee (JNC) on the prevention, detection, evaluation, and treatment of high BP is one of the foremost regional regulatory bodies on the management of hypertension.


  Joint National Committee-8 Recommendations Top


The latest review of the management of hypertension by the JNC was published in 2014 as JNC-8. [Table 1] contains summaries of the report.[6] Evidence for their recommendations was drawn from randomized control trials (RCTs).[6] Evidence quality and recommendations were graded based on their effect on important outcomes. James et al. commenting on JNC-8 stated that the work set out to synthesize the latest available scientific evidence and update existing clinical recommendations on hypertension control in order to minimize patients' risk for cardiovascular and other complications.
Table 1: The summaries of Joint National Committee-8 recommendations

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Reactions

In JNC-8, the critical questions and review criteria were defined by an expert panel with input from the methodology team, followed by initial systematic review by methodologists restricted to RCT evidence.[6],[7] Subsequent review of RCT evidence and recommendations were made by the panel according to the standard protocol.[6],[7] In JNC-7, methodology was based on nonsystematic literature review by an expert committee including a range of study designs, and recommendations were made based on consensus.[7],[8] This change is said to be an improvement on the previous process of the past JNCs.[9]

However, JNC-8 report remains a guide not a law and it is not meant to substitute clinical judgment.[6],[10] This supports the opinion of some critics that it is not given that clinical practice guidelines benefit patients.[11]

Despite all the work, 6 of 11 recommendations had to be based on expert opinions (Grade E).[6],[10]

In June 2013, the National Heart Lung and Blood Institute (NHLBI) announced its decision to discontinue developing clinical guidelines including those in process; instead, they would develop systematic reviews and work with external stakeholders in developing guidelines.[12] NHLBI neither did endorse JNC-8 nor did any US federal agency.[6] JNC-7 which was a review by 39 professional, public, and voluntary organizations and seven federal agencies had wide acceptance. In contrast, JNC-8 was a review by selected 16 individual experts and five federal agencies.[13]

Uncertain confidence toward the JNC-8 started after the NHBLI made that announcement and turned the guideline development process to the American Heart Association and American College of Cardiology, but both associations with this new mandate did not review the JNC-8 report before its publication.[9]

There still remains the issue of nonagreeability on BP targets for the commencement of antihypertensive which leaves the clinician to use their best judgment for their individual patients.[6],[10],[14] The 2013 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines for the management of arterial hypertension agreed with recommendation 1 of the JNC-8,[15] following the findings of Hypertension in the Very Elderly Trial.[16] The 2013 ESH/ESC further suggested that for elderly people <80 years of age who are fit and can tolerate it considering a systolic BP (SBP) of <140 mmHg goal would also be beneficial. There is a similar additional consideration in the recommendation 1 of JNC-8, but it has no age upper limit.[6] The SBP cutoff for initiation of therapy and goal in the general population 60 years and above is the most important source of disagreement.[17],[18] The South African Hypertension Practice Guideline 2014 out-rightly rejected recommendation 1 of the JNC-8[19] and others expressed concern regarding the recommendation.[13] Some would consider this recommendation the most controversial [13] while another angle to the controversy would be that there were no Blacks in the two major studies – the Valsartan in Elderly Isolated Systolic Hypertension [20] and JATOS [21] trials – used.

The fourth recommendation did not reflect the comprehensive advice of the expert committee in its discussion on BP management in patients with chronic kidney disease and proteinuria (especially in the elderly).[6],[13]

There are also objections to fifth recommendation citing strict criteria for inclusion of studies as an obstacle to flexibility,[13] and this recommendation is in conflict with Kidney Disease: Improving Global Outcomes guideline,[22] American Diabetic Association,[23] and ESH/ESC guideline [15] on BP goals in patients with diabetes.

The last recommendation failed to say what the qualification of the hypertension specialist should be.[13]


  Conclusion Top


The JNC-8 has been strongly criticized, especially the first recommendation which happens to bear a Grade A level of confidence.[6] The process was more in agreement with the Institute of Medicine guidelines than the previous JNC, but it has come under criticism for excluding too many publications and having to work with too few publications (especially for recommendation 1) in coming up with their final recommendations.[10],[13],[17],[18] Global guidelines need to be more complementary and fundamentally reflect similar viewpoints. It is belated for Sub-Saharan Africa to come up with an international guideline on hypertension since we carry a large burden of the diseases attributable to hypertension and some of these recommendations are based on studies which excluded Blacks.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lawes CM, Vander Hoorn S, Rodgers A; International Society of Hypertension. Global burden of blood-pressure-related disease, 2001. Lancet 2008;371:1513-8.  Back to cited text no. 1
    
2.
Fields LE, Burt VL, Cutler JA, Hughes J, Roccella EJ, Sorlie P. The burden of adult hypertension in the United States 1999 to 2000: A rising tide. Hypertension 2004;44:398-404.  Back to cited text no. 2
    
3.
Ong KL, Cheung BM, Man YB, Lau CP, Lam KS. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension 2007;49:69-75.  Back to cited text no. 3
    
4.
Ogah OS, Okpechi I, Chukwuonye II, Akinyemi JO, Onwubere BJ, Falase AO, et al. Blood pressure, prevalence of hypertension and hypertension related complications in Nigerian Africans: A review. World J Cardiol 2012;4:327-40.  Back to cited text no. 4
    
5.
Country and Lending Groups | Data. The World Bank; 2015. Available from: http://www.data.worldbank.org. [Last accessed on 2016 Jun 29].  Back to cited text no. 5
    
6.
James PA, Oparil S, Carter BL, Cushman WC, Dennison-Himmelfarb C, Handler J, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: Report from the panel members appointed to the Eight Joint National Committee (JNC 8). JAMA 2014;311:507-20.  Back to cited text no. 6
    
7.
Mahajan R. Joint National Committee 8 report: How it differs from JNC 7. Int J Appl Basic Med Res 2014;4:61-2.  Back to cited text no. 7
    
8.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr., et al. Seventh report of the Joint National Committee on prevention, detection, evaluation, and treatment of high blood pressure. Hypertension 2003;42:1206-52.  Back to cited text no. 8
    
9.
Sox HC. Assessing the trustworthiness of the guideline for management of high blood pressure in adults. JAMA 2014;311:472-4.  Back to cited text no. 9
    
10.
Black HR. JNC 8 Reviewed. Medscape Cardiology; 2013. Available from: http://www.medscape.com/viewarticle/818018_5. [Last accessed on 2016 Jun 29].  Back to cited text no. 10
    
11.
Woolf SH, Grol R, Hutchinson A, Eccles M, Grimshaw J. Clinical guidelines: Potential benefits, limitations, and harms of clinical guidelines. BMJ 1999;318:527-30.  Back to cited text no. 11
    
12.
Gibbons GH, Shurin SB, Mensah GA, Lauer MS. Refocusing the agenda on cardiovascular guidelines: An announcement from the National Heart, Lung, and Blood Institute. Circulation 2013;128:1713-5.  Back to cited text no. 12
    
13.
Reisin E, Harris RC, Rahman M. Commentary on the 2014 BP guidelines from the panel appointed to the Eighth Joint National Committee (JNC 8). J Am Soc Nephrol 2014;25:2419-24.  Back to cited text no. 13
    
14.
Hernandez-Vila E. A review of the JNC 8 blood pressure guideline. Tex Heart Inst J 2015;42:226-8.  Back to cited text no. 14
    
15.
Mancia G, Fagard R, Narkiewicz K, Redon J, Zanchetti A, Böhm M, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J 2013;34:2159-219.  Back to cited text no. 15
    
16.
Beckett NS, Peters R, Fletcher AE, Staessen JA, Liu L, Dumitrascu D, et al. Treatment of hypertension in patients 80 years of age or older. N Engl J Med 2008;358:1887-98.  Back to cited text no. 16
    
17.
Krakoff LR, Gillespie RL, Ferdinand KC, Fergus IV, Akinboboye O, Williams KA, et al. 2014 hypertension recommendations from the Eighth Joint National Committee panel members raise concerns for elderly black and female populations. J Am Coll Cardiol 2014;64:394-402.  Back to cited text no. 17
    
18.
Wright JT Jr., Fine LJ, Lackland DT, Ogedegbe G, Dennison Himmelfarb CR. Evidence supporting a systolic blood pressure goal of less than 150 mm Hg in patients aged 60 years or older: The minority view. Ann Intern Med 2014;160:499-503.  Back to cited text no. 18
    
19.
Seedat YK, Rayner BL; Southern African Hypertension Society. South African hypertension guideline 2011. S Afr Med J 2011;102(1 Pt 2):57-83.  Back to cited text no. 19
    
20.
Ogihara T, Saruta T, Matsuoka H, Shimamoto K, Fujita T, Shimada K, et al. valsartan in elderly isolated systolic hypertension (VALISH) study: Rationale and design. Hypertens Res 2004;27:657-61.  Back to cited text no. 20
    
21.
JATOS Study Group. Principal results of the Japanese trial to assess optimal systolic blood pressure in elderly hypertensive patients (JATOS). Hypertens Res 2008;31:2115-27.  Back to cited text no. 21
    
22.
Kidney Disease: Improving Global Outcomes Blood Pressure Work Group. KDIGO clinical practice guidelines for the management of blood pressure in chronic kidney disease. Kidney Int 2012;2:337-414.  Back to cited text no. 22
    
23.
American Diabetes Association. Standards of Medical Care in Diabetes – 2013. Diabetes Care. Available from: http://www.care.diabetesjournals.org. [Last accessed on 2016 Jun 29].  Back to cited text no. 23
    



 
 
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