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Review Article

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

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

Address for correspondence: Dr. Ogba Joseph Ukpabi, Department of Internal Medicine, Federal Medical Center, Umuahia, Abia State, Nigeria.
E‑mail: ojukpabi@yahoo.com

INTRODUCTION hypertension and recommend guidelines. The WHO

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
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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
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How to cite this article: Ukpabi OJ, Ewelike ID. The eighth joint national
DOI: committee on the prevention, detection, evaluation, and treatment of high
10.4103/0189-7969.201909 blood pressure (joint national committee-8) report: Matters arising. Nig J
Cardiol 2017;14:15-8.

© 2017 Nigerian Journal of Cardiology | Published by Wolters Kluwer - Medknow 15

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Ukpabi and Ewelike: Matters arising from JNC‑8
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.
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
16 Nigerian Journal of Cardiology
Table 1: The summaries of Joint National Committee‑8
recommendations
Recommendation 1
In the general population aged ≥60 years, initiate pharmacologic
treatment to lower BP at SBP ≥150 mmHg or DBP≥90 mmHg and
treat to a goal SBP <150 mmHg and goal DBP<90 mmHg (strong
recommendation ‑ Grade A)
Corollary recommendation
In the general population aged ≥60 years, if pharmacologic treatment
for high BP results in lower achieved SBP (e.g., <140 mmHg) and
treatment is well tolerated and without adverse effects on health
or quality of life, treatment does not need to be adjusted (expert
opinion ‑ Grade E)
Recommendation 2
In the general population <60 years, initiate pharmacologic treatment
to lower BP at DBP ≥90 mmHg and treat to a goal DBP <90 mmHg. (for
ages 30-59 years, strong recommendation ‑ Grade A; for ages
18-29 years, expert opinion ‑ Grade E)
Recommendation 3
In the general population <60 years, initiate pharmacologic treatment
to lower BP at SBP ≥140 mmHg and treat to a goal SBP <140 mmHg
(expert opinion ‑ Grade E)
Recommendation 4
In the population aged ≥18 years with CKD, initiate pharmacologic
treatment to lower BP at SBP ≥140 mmHg or DBP ≥90 mmHg and
treat to goal SBP <140 mmHg and goal DBP <90 mmHg
(expert Opinion ‑ Grade E)
Recommendation 5
In the population aged ≥18 years with diabetes, initiate
pharmacologic treatment to lower BP at SBP≥140 mmHg or DBP ≥90
mmHg and treat to a goal SBP<140 mmHg and goal DBP <90 mmHg
(expert opinion ‑ Grade E)
Recommendation 6
In the general non‑Black population, including those with diabetes,
initial antihypertensive treatment should include a thiazide‑type
diuretic, CCB, ACEI, or ARB (moderate recommendation ‑ Grade B)
Recommendation 7
In the general Black population, including those with diabetes,
initial antihypertensive treatment should include a thiazide‑type
diuretic or CCB (For general Black population: moderate
recommendation – Grade B; For Black patients with diabetes: weak
recommendation – Grade C)
Recommendation 8
In the population aged ≥18 years with CKD, initial (or add‑on)
antihypertensive treatment should include an ACEI or ARB to
improve kidney outcomes. This applies to all CKD patients with
hypertension regardless of race or diabetes status (moderate
recommendation ‑ Grade B)
Recommendation 9
The main objective of hypertension treatment is to attain and maintain
goal BP. If goal BP is not reached within a month of treatment, increase
the dose of the initial drug or add a second drug from one of the classes
in recommendation 6 (thiazide‑type diuretic, CCB, ACEI, or ARB).
The clinician should continue to assess BP and adjust the treatment
regimen until goal BP is reached. If goal BP cannot be reached with
two drugs, add and titrate a third drug from the list provided. Do not
use an ACEI and an ARB together in the same patient. If goal BP cannot
be reached using only the drugs in recommendation 6 because of a
contraindication or the need to use more than three drugs to reach goal
BP, antihypertensive drugs from other classes can be used. Referral to
a hypertension specialist may be indicated for patients in whom goal
BP cannot be attained using the above strategy or for the management
of complicated patients for whom additional clinical consultation is
needed (expert opinion ‑ Grade E)
BP ‑ Blood pressure; SBP ‑ Systolic blood pressure; DBP ‑ Diastolic
blood pressure; CKD ‑ Chronic kidney disease; CCB ‑ Calcium
channel blocker; ACEI ‑ Angiotensin‑converting enzyme inhibitor;
ARB ‑ Angiotensin receptor blocker
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Ukpabi and Ewelike: Matters arising from JNC‑8
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
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.
Nigerian Journal of Cardiology | Volume 14 | Issue 1 | January-June 2017 17
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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