Nigerian Journal of Cardiology

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


Ogba Joseph Ukpabi, Iheanyi Damian Ewelike 
 Department of Internal Medicine, Federal Medical Centre, Umuahia, Abia State, Nigeria

Correspondence Address:
Ogba Joseph Ukpabi
Department of Internal Medicine, Federal Medical Center, Umuahia, Abia State
Nigeria

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.



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;14:15-18


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 2020 Oct 24 ];14:15-18
Available from: https://www.nigjcardiol.org/text.asp?2017/14/1/15/201909


Full Text

 Introduction



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



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}

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 [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



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

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