COMMENTARY
Special Focus Issue on Hypertension Guidelines
JNC 8 at Last! No Holy Grail in Hand, but Useful Recommendations Barry J. Materson, MD, MBA From the Divisions of Clinical Pharmacology and Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
To the credit of the panel members of the Eighth Joint National Committee (JNC 8), their recommendations have been published independently from the National Heart, Lung, and Blood Institute (NHLBI) and are now available for consideration by practitioners who provide care to patients with hypertension.1 I briefly reviewed the JNC 8 process that was in the public domain by May 2013 and compared it with the JNC 7 process.2 JNC 8 was initiated in March 2008. The completed report was sent out for review in January 2013. In June 2013, the NHLBI decided not to be involved in the generation of guidelines and recommendations. The expert panel, without NHLBI sanction, published their report online in December 2013 and print publication will be in January 2014. JNC 7 was initiated in December 2002 and had its short report published in May 20033 and a detailed report published in December 2003.4 Table 1 of the JNC 8 report provides a detailed comparison. The bulk of JNC 7 was left intact. For example, the JNC 7 designation of prehypertension was not challenged. JNC 7 remains a very solid document for students and practitioners of hypertension prevention, diagnosis, evaluation, and treatment. Despite the intensive effort to be evidence-based, 6 of the 9 recommendations are expert opinion, grade E. Only one is a grade A (strong) recommendation and two are grade B (moderate) recommendations. The corollary recommendation to Recommendation 1 is grade E expert opinion. Recommendation 7 contains one grade B recommendation and one grade C (weak) recommendation. Therefore, after years of search for the Holy Grail of Guidelines/Recommendations, the majority of recommendations depended on the considerable experience and intellect of the panel members. They had the courage to publish their findings and recommendations independent of the sponsoring organization. The panel acknowledged that restricting data only to randomized clinical trials limited the evidence base. Many of these classic studies are older and were performed before the beneficial impact of prior recommendations on hypertension-related morbidity and mortality was realized. The population captured by these clinical trials may not be representative of modern Address for correspondence: Barry J. Materson, MD, MBA, Department of Medicine, University of Miami (D54), PO Box 016960, Miami, FL 33101 E-mail: [email protected] DOI: 10.1111/jch.12283
populations. Older studies focused on diastolic pressure so that strong evidence on systolic pressure was not available. Despite this, the panel did base recommendations for systolic pressure on their best expert opinion. Many drugs were omitted from listing in Table 4 because evidence that met the strict inclusion criteria was not available. The hypertension guideline management algorithm is an improvement over that published by JNC 7. It incorporates the revised blood pressure recommendations and adds a choice of three treatment titration strategies. It includes the recommendations for patients age 60 and older. This is a significant change and one that is highly controversial. It also incorporates recommendations for treatment that may be race-sensitive and for specific comorbidities (diabetes, chronic kidney disease). Combination therapy (single-pill or fixed-dose) is included. This should help reduce the considerable current uncertainty regarding appropriate treatment. The long delay between the publication of JNC 7 (2003) and JNC 8 coupled with the high level of secrecy surrounding JNC 8 resulted in a number of organizations deciding to go their own way. ASH/ISH addressed a somewhat different audience—one that works in areas that might have limited or even severely limited resources. This set of guidelines was published in the January 2014 issue of The Journal of Clinical Hypertension.5 They provided a useful algorithm. The European Society of Hypertension/European Society of Cardiology (ESH/ESC) published their very detailed, color-coded, 77-page guidelines with 735 references in July 2013.6 Unfortunately, these and other publications detract from the time and effort spent by the JNC 8 panel. Table 6 of JNC 8 compares their recommendations with the goal blood pressures and recommendation for initial drug therapy of 6 other organizations. In general, there is agreement in most areas. The International Society on Hypertension in Blacks 20107 was the most stringent in that they recommended
Special Focus Issue on Hypertension Guidelines
JNC 8 at Last! No Holy Grail in Hand, but Useful Recommendations Barry J. Materson, MD, MBA From the Divisions of Clinical Pharmacology and Hospital Medicine, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
To the credit of the panel members of the Eighth Joint National Committee (JNC 8), their recommendations have been published independently from the National Heart, Lung, and Blood Institute (NHLBI) and are now available for consideration by practitioners who provide care to patients with hypertension.1 I briefly reviewed the JNC 8 process that was in the public domain by May 2013 and compared it with the JNC 7 process.2 JNC 8 was initiated in March 2008. The completed report was sent out for review in January 2013. In June 2013, the NHLBI decided not to be involved in the generation of guidelines and recommendations. The expert panel, without NHLBI sanction, published their report online in December 2013 and print publication will be in January 2014. JNC 7 was initiated in December 2002 and had its short report published in May 20033 and a detailed report published in December 2003.4 Table 1 of the JNC 8 report provides a detailed comparison. The bulk of JNC 7 was left intact. For example, the JNC 7 designation of prehypertension was not challenged. JNC 7 remains a very solid document for students and practitioners of hypertension prevention, diagnosis, evaluation, and treatment. Despite the intensive effort to be evidence-based, 6 of the 9 recommendations are expert opinion, grade E. Only one is a grade A (strong) recommendation and two are grade B (moderate) recommendations. The corollary recommendation to Recommendation 1 is grade E expert opinion. Recommendation 7 contains one grade B recommendation and one grade C (weak) recommendation. Therefore, after years of search for the Holy Grail of Guidelines/Recommendations, the majority of recommendations depended on the considerable experience and intellect of the panel members. They had the courage to publish their findings and recommendations independent of the sponsoring organization. The panel acknowledged that restricting data only to randomized clinical trials limited the evidence base. Many of these classic studies are older and were performed before the beneficial impact of prior recommendations on hypertension-related morbidity and mortality was realized. The population captured by these clinical trials may not be representative of modern Address for correspondence: Barry J. Materson, MD, MBA, Department of Medicine, University of Miami (D54), PO Box 016960, Miami, FL 33101 E-mail: [email protected] DOI: 10.1111/jch.12283
populations. Older studies focused on diastolic pressure so that strong evidence on systolic pressure was not available. Despite this, the panel did base recommendations for systolic pressure on their best expert opinion. Many drugs were omitted from listing in Table 4 because evidence that met the strict inclusion criteria was not available. The hypertension guideline management algorithm is an improvement over that published by JNC 7. It incorporates the revised blood pressure recommendations and adds a choice of three treatment titration strategies. It includes the recommendations for patients age 60 and older. This is a significant change and one that is highly controversial. It also incorporates recommendations for treatment that may be race-sensitive and for specific comorbidities (diabetes, chronic kidney disease). Combination therapy (single-pill or fixed-dose) is included. This should help reduce the considerable current uncertainty regarding appropriate treatment. The long delay between the publication of JNC 7 (2003) and JNC 8 coupled with the high level of secrecy surrounding JNC 8 resulted in a number of organizations deciding to go their own way. ASH/ISH addressed a somewhat different audience—one that works in areas that might have limited or even severely limited resources. This set of guidelines was published in the January 2014 issue of The Journal of Clinical Hypertension.5 They provided a useful algorithm. The European Society of Hypertension/European Society of Cardiology (ESH/ESC) published their very detailed, color-coded, 77-page guidelines with 735 references in July 2013.6 Unfortunately, these and other publications detract from the time and effort spent by the JNC 8 panel. Table 6 of JNC 8 compares their recommendations with the goal blood pressures and recommendation for initial drug therapy of 6 other organizations. In general, there is agreement in most areas. The International Society on Hypertension in Blacks 20107 was the most stringent in that they recommended
