JNC 8 Versus JNC 7 – Understanding The Evidences
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-43ISSN 0976 – 044XResearch ArticleJNC 8 versus JNC 7 – Understanding the EvidencesAnns Clara Joseph, Karthik MS, Sivasakthi R, Venkatanarayanan R, Sam Johnson Udaya Chander J*RVS College of Pharmaceutical Sciences, Coimbatore, TN, India.*Corresponding author’s E-mail: mail2samjohnson@gmail.comAccepted on: 15-10-2015; Finalized on: 31-12-2015.ABSTRACTHypertension is growing as a global burden now. It is essential to provide a standard and harmonized guideline for hypertensiontreatment. There is strong evidence to support treating hypertensive persons aged 60 years or older to a BP goal of less than 150/90mmHg, however, there is insufficient evidence in hypertensive persons younger than 60 years for a systolic goal, or in those youngerthan 30 years for a diastolic goal, so the panel of Eighth Joint National Committee (JNC 8) recommends a BP of less than 140/90mmHg for those groups based on expert opinion. The same thresholds and goals are recommended for hypertensive adults withdiabetes or nondiabetic chronic kidney disease (CKD) as for the general hypertensive population younger than 60 years. There ismoderate evidence to support initiating drug treatment with an angiotensin-converting enzyme inhibitor, angiotensin receptorblocker, calcium channel blocker, or Thiazide-type diuretic in the nonblack hypertensive population, including those with diabetes.In the black hypertensive population, including those with diabetes, a calcium channel blocker or Thiazide-type diuretic isrecommended as initial therapy. There is moderate evidence to support initial or add-on antihypertensive therapy with anangiotensin-converting enzyme inhibitor or angiotensin receptor blocker in persons with CKD to improve kidney outcomes. Thiseducational material debates the recommendations and limitations of JNC 8 Guidelines in the management of hypertension.Keywords: JNC 8 Guidelines, Chronic Kidney Disease, Diabetes mellitus, diuretic, angiotensin-converting enzyme inhibitor,angiotensin receptor blocker.INTRODUCTIONIn present scenario one of the most common conditionseen in primary care is hypertension, which leads tostroke, renal failure, myocardial infarction and death ifnot detected early and treated appropriately. Patientswant to be assured that blood pressure (BP) treatmentwill reduce their disease burden, while clinicians wantguidance on hypertension management using the bestscientific evidence.1 Many guidelines are available for thetreatment of hypertension. Each one was developed aftercontinuous study and randomized control trials. endations for the management of hypertensionand meet the clinical needs of most patients, these arenot a substitute for clinical judgment, and decisions aboutcare must carefully consider and incorporate the clinicalcharacteristics and circumstances of each individualpatient.2JNC (Joint National Committee)Joint National Committee is a panel appointed by theNational Heart, Lung, and Blood Institute (NHLBI). Thefirst guidelines (JNC-1) was published in 1977, subsequentupdates were published in 3 to 6 year intervals, JNC-2(1980), JNC-3 (1984), JNC-4 (1988), JNC-5 (1992), JNC-6(1997), and JNC-7 (2004) and the latest edition is JNC-8published in 2013.3Development of JNC-8It was commissioned by the NHLBI in 2008. Panelmembers were appointed and developed focused criticalquestions relevant to practice. Then, they conducted asearch of literature. It is limited to randomized controlledtrials (RCTs) published between 1966 and 2009. Thisincluded a sample of 100 patients or more who were 18years and above with hypertension. Subsequent search ofstudies from 2009 to 2013 required samples of 2000 ormore patients. The panel members raised three criticalquestions for adults with hypertension:–Does initiating antihypertensive pharmacologictherapy at specific blood pressure thresholdsimprove health outcomes? [When to start therapy?]–Does treatment with antihypertensive pharmacologictherapy to a specified blood pressure goal lead toimprovements in health outcomes? [How low shouldI go?]–Do various antihypertensive drugs or drug classesdiffer in comparative benefits and harms on specifichealth outcomes? [What drug do I use?]In 2013, the NHLBI decided that it will no longer publishclinical guidelines, proposed to work collaboratively withother organizations. The appointed panel members forJNC-8 decided to publish their findings independently andpublished online in JAMA in December 2013, received noendorsements from other organizations. A multitude ofother hypertension guidelines were also published in2013 viz.; AHA/ACC/CDC advisory algorithm, AmericanSociety of Hypertension/International Society ion and European Society of CardiologyInternational Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.38 Copyright pro
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-43(ESH/ESC), andProgram (CHEP).4CanadianHypertensionEducationJNC-8 RecommendationsThe following recommendations were based on thesystematic evidence review. Recommendations 1 through5 address questions 1 and 2 concerning thresholds andgoals for BP treatment. Recommendations 6, 7, and 8address question 3 concerning selection ofantihypertensive drugs.Recommendation 9 is a summary of strategies based onexpert opinion for starting and adding ingrecommendations are in the online supplement.theISSN 0976 – 044XRecommendation 6In the general nonblack population, including those withdiabetes, initial antihypertensive treatment shouldinclude a Thiazide-type diuretic, calcium channel blocker(CCB), angiotensin-converting enzyme inhibitor (ACEI), orangiotensin receptor blocker (ARB). ModerateRecommendation – Grade B)Recommendation 7In the general black population, including those withdiabetes, initial antihypertensive treatment shouldinclude a Thiazide-type diuretic or CCB. (For general blackpopulation: Moderate Recommendation – Grade B; forblack patients with diabetes: Weak Recommendation –Grade C)Recommendation 8Recommendation 1In the general population aged 60 years and above,initiate pharmacologic treatment to lower blood pressure(BP) at systolic blood pressure (SBP) 150 mmHg ordiastolic blood pressure (DBP) 90 mmHg and treat to agoal SBP 150 mmHg and goal DBP 90mm Hg. (StrongRecommendation – Grade A)In the population aged 18 years and above with CKD,initial (or add-on) antihypertensive treatment shouldinclude an ACEI or ARB to improve kidney outcomes. Thisapplies to all CKD patients with hypertension regardlessof race or diabetes status. (Moderate Recommendation –Grade B)Recommendation 9Corollary RecommendationIn the general population aged 60 years and above, ifpharmacologic treatment for high BP results in lowerachieved SBP (for example, 140 mmHg) and treatment iswell tolerated and without adverse effects on health orquality of life, treatment does not need to be adjusted.Recommendation 2In the general population less than 60 years, initiatepharmacologic treatment to lower BP at DBP 90 mmHgand treat to a goal DBP 90mm Hg.(For ages 30-59 years, Strong Recommendation – GradeA; For ages 18-29 years, Expert Opinion – Grade E)Recommendation 3In the general population less than 60 years, initiatepharmacologic treatment to lower BP at SBP 140 mmHgand treat to a goal SBP 140 mmHg. (Expert Opinion –Grade E)Recommendation 4In the population aged 18 years and above with chronickidney disease (CKD), initiate pharmacologic treatment tolower BP at SBP 140 mmHg or DBP 90 mmHg and treatto goal SBP 140 mmHg and goal DBP 90 mmHg. (ExpertOpinion – Grade E)Recommendation 5In the population aged 18 years and above with diabetes,initiate pharmacologic treatment to lower BP at SBP 140mmHg or DBP 90 mmHg and treat to a goal SBP 140mmHg and goal DBP 90 mmHg. (Expert Opinion – GradeE)The main objective of hypertension treatment is to attainand maintain goal BP. If goal BP is not reached within amonth of treatment, increase the dose of the initial drugor add a second drug from one of the classes inrecommendation 6 (Thiazide-type diuretic, CCB, ACEI, orARB).The clinician should continue to assess BP and adjust thetreatment regimen until goal BP is reached. If goal BPcannot be reached with two drugs, add and titrate a thirddrug from the list provided. Do not use an ACEI and anARB together in the same patient.If goal BP cannot be reached using only the drugs inrecommendation 6 because of a contraindication or theneed 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 forpatients in whom goal BP cannot be attained using theabove strategy or for the management of complicatedpatients for whom additional clinical consultation isneeded. (Expert Opinion – Grade E).5,6Comparison Between JNC-7 and JNC-8JNC-7 Blood Pressure Classification7Blood PressureClassificationNormalSystolic bloodpressure(mmHg) 120andDiastolic bloodpressure(mmHg) 80Pre-hypertension120-139or80-89Stage 1 hypertension140-159or90-99Stage 2 hypertension 160or 100International Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.39 Copyright pro
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-43JNC-7 Treatment Algorithm7ISSN 0976 – 044XHypertension Classification According to JNC 8Source: Chobanian AV, Bakris GL, Black HR. SeventhReport of the Joint National Committee on Prevention,Detection, Evaluation, and Treatment of High BloodPressure. Hypertension, 42, 2003, 1206-52.General Population (No CKD/DM)DM and CKD PresentSummary of JNC 7 and JNC 8 RecommendationsInternational Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.40 Copyright pro
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-43ISSN 0976 – 044XTopicJNC 7JNC 8Methodology Nonsystematic literature review by expertcommittee including a range of study designs.Recommendations based on consensus.Critical questions and review criteria defined byexpert panel with input from gists restricted to RCT evidence.Subsequent review of RCT evidence andrecommendations by the panel according to astandardized protocol. Definitions Defined hypertension and pre-hypertension. Definitions of hypertension and prehypertension not addressed, but thresholds forpharmacologic treatment were defined.Treatment Goals � hypertension and for subsetswith various comorbid conditions (diabetes andCKD). Similar treatment goals defined for allhypertensive populations except when evidencereview supports different goals for a particularsubpopulation.Lifestyle recommendations Recommended lifestyle modifications based onliterature review and expert opinion. Lifestyle modifications recommended byendorsingtheevidencebasedrecommendations of the Lifestyle Work Group.Drug therapy Recommended five classes to be considered asinitial therapy, but recommended thiazide-typediuretics as initial therapy for most patientswithout compelling indication for another class.Specified particular antihypertensive medicationclasses for patients with compelling indications,ie, diabetes, CKD, heart failure, myocardialinfarction, stroke, and high CVD risk.Included a comprehensive table of oralantihypertensive drugs including names andusual dose range. Recommended selection among four specificmedication classes (ACEI or ARB, CCB ordiuretics) and doses based on RCT evidence.Recommended specific medication classesbased on evidence review for racial, CKD, anddiabetic subgroups.Panel created a table of drugs and doses used inthe outcome trials. Scope of topics Addressed multiple issues (blood pressuremeasurement methods, patient ce to regimens, resistant hypertension,and hypertension in special populations) basedon literature review and expert opinion. Evidence review of RCTs addressed a limitednumber of questions, those judged by the panelto be of highest priority.Review process prior topublication Reviewed by the National High Blood PressureEducation Program Coordinating Committee, acoalition of 39 major professional, public, andvoluntary organizations and 7 federal agencies. Reviewed by experts including those affiliatedwith professional and public organizations andfederal agencies.No official sponsorship by any organizationshould be inferred. Source: James PA, Oparil S, Carter BL. Evidence-based guideline for the management of high blood pressure in adults.Report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 311(5), 2014, 507-20.Comparison with other Guidelines8BP GoalAgeJNC-7JNC-8ASH/ISHESC/ESHAge 60 140/90 140/90 140/90 140/90Age 60-79 140/90 150/90 140/90 140/90Age 80 140/90 150/90 150/90 150/90Diabetes 130/80 140/90 140/90 140/85CKD 130/80 140/90 140/90 130/90Non-black (no DM or CKD)ThiazideThiazide, ACEI, ARB, CCB 60: ACEI, ARBThiazide, ACEI, ARB, CCB,BBBlack (no DM or CKD)ThiazideThiazide, CCBThiazide, CCBThiazide, ACEI, ARB, CCB,BBDiabetesACEI, ARB, CCB, BB,ThiazideCCB, ThiazideACEI, ARB, CCB, ThiazideACEI, ARBCKDACEI, ARBACEI, ARBACEI, ARBACEI, ARBCo-morbiditiesTherapy 60: CCB, ThiazideInternational Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.41 Copyright pro
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-43Limitations of JNC 8 GuidelineJNC 8 guideline is not a comprehensive guideline and islimited in scope because of the focused evidence reviewto address the three specific questions. The decision onchoice of drug was made to focus on three questionsconsidered to be relevant to most physicians andpatients. Treatment adherence and medication costswere thought to be beyond the scope of this review, butthe reviewers acknowledge the importance of bothissues. In addition, the ability to compare studies fromdifferent time periods was limited by differences inclinical trial design and analytic techniques. Moreover,this guideline was not endorsed by any federal agency orprofessional society prior to publication and thus is adeparture from previous JNC reports.9DISCUSSIONThe recommendations based on RCT evidence in thisguideline differ from recommendations in other currentlyused guidelines supported by expert consensus. Forexample, JNC 7 and other guidelines recommendedtreatment to lower BP goals in patients with diabetes andCKD based on observational studies.4 There are ninerecommendations given in JNC 8, if older than 60 years,the new guideline is to treat for a blood pressure of lessthan 150/90 mm Hg. If younger than 60 years, the goal isless than 140/90 mm Hg. For patients who have kidneydisease and diabetes, the goal is 140/90 mm Hg. Thiazidediuretics, CCB, ARBS, and ACEIs are the four drug classsuggested as first line therapy. Alpha- and beta-blockerswere not recommended for initial therapy, alphablockers: worse cerebrovascular, heart failure, andcombined cardiovascular outcomes vs initial treatmentwith a diuretic and beta-blockers lead to higher rate ofprimary composite outcome of cardiovascular death, MI,or stroke compared with use of an ARB.10 It takes a lot oftime for physicians to instruct patients and to get themon board with the new goals and to have the patientsactually know their numbers, to be invested in thenumbers. With these new guidelines, patient educationhas obviously changed, and this confusion can create a lotof issues. Guideline writers should come to a consensus.The guideline was published in JAMA, and the opposingviews were in the Annals of Internal Medicine. This makesit difficult for the practicing physician to try and sort outthe pertaining issues.11 The observations from a studyconducted by current researchers MSK and ACJ onassessment of prescribing pattern in hypertensivepatients and comparison with JNC 8 guidelines shows thatmost of the prescriptions (56%) were not following theJNC 8 guideline. This recommends the policy makers ofthe country to make the practicing physicians aware ofthe JNC 8 guideline, and if possible, adopt the same.CONCLUSIONIt is important to note that this evidence-based guidelinehas not redefined high BP, and the panel believes that the140/90 mmHg definition from JNC 7 remains reasonable.ISSN 0976 – 044XThe relationship between naturally occurring BP and riskis linear down to very low BP, but the benefit of treatingto these lower levels with antihypertensive drugs is notestablished. For all persons with hypertension, thepotential benefits of a healthy diet, weight control, andregular exercise cannot be over emphasized. Theselifestyle treatments have the potential to improve BPcontrol and even reduce medication needs. Therecommendations from this evidence-based guidelinefrom panel members appointed to the Eighth JointNational Committee (JNC 8) offer clinicians an analysis ofwhat is known and not known about BP treatmentthresholds, goals, and drug treatment strategies toachieve those goals based on evidence from RCTs.However, these recommendations are not a substitutefor clinical judgment, and decisions about care mustcarefully consider and incorporate the clinicalcharacteristics and circumstances of each individualpatient. We hope that the algorithm will facilitateimplementation and be useful to busy clinicians. Thestrong evidence base of this report should inform qualitymeasures for the treatment of patients withhypertension; however, JNC 8 guideline are evidencebased, more simplified, with clear-cut target range and itcan surely serve a handy reference in the hands ofclinicians and clinical pharmacists in managinghypertensive patients.Conflict of Interest: None.REFERENCES1.Staessen JA, Fagard R, Thijs L; The Systolic Hypertension inEurope (Syst-Eur) Trial Investigators. Randomized doubleblind comparison of placebo and active treatment for olderpatients with isolated systolic hypertension. Lancet.350(9080), 1997, 757-64.2.Beckett NS, Peters R, Fletcher AE; HYVET Study Group.Treatment of hypertension in patients 80 years of age orolder. N Engl J Med. 358(18), 2008, 1887-98.3.The seventh report of the Joint National Committee onPrevention, Detection, Evaluation and Treatment of HighBlood Pressure (JNC 7): Hypertension, 42, 2003, 1206.4.Chobanian AV, Bakris GL, Black HR; National Heart, Lung,and Blood Institute Joint National Committee onPrevention, Detection, Evaluation, and Treatment of HighBlood Pressure; National High Blood Pressure EducationProgram Coordinating Committee. The seventh report ofthe Joint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure: the JNC7 report. JAMA. 289(19), 2003, 2560-72.5.JATOS Study Group. Principal results of the Japanese trialto assess optimal systolic blood pressure in elderlyhypertensive patients (JATOS). Hypertension Research.31(12), 2008, 2115-27.6.Ogihara T, Saruta T, Rakugi H, Valsartan in Elderly IsolatedSystolic Hypertension Study Group. Target blood pressurefor treatment of isolated systolic hypertension in theelderly: Valsartan in Elderly Isolated Systolic HypertensionStudy. Hypertension. 56(2), 2010, 196-202.International Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.42 Copyright pro
Int. J. Pharm. Sci. Rev. Res., 36(1), January – February 2016; Article No. 06, Pages: 38-437.Chobanian AV, Bakris GL, Black HR. Seventh Report of theJoint National Committee on Prevention, Detection,Evaluation, and Treatment of High Blood Pressure.Hypertension, 42, 2003, 1206-52.8.Adapted from Salvo M. Ann Pharmacother, 48, 2014, 12428.9.Paul A. James, MD; Suzanne Oparil, MD; Barry L. Carter,William C. 2014 Evidence-Based Guideline for theManagement of High Blood Pressure in Adults. ReportFrom the Panel Members Appointed to the Eighth JointISSN 0976 – 044XNational Committee (JNC 8). JAMA. Published onlineDecember 18, 2013.10. James PA, Oparil S, Carter BL. 2014 Evidence-basedguideline for the management of high blood pressure inadults. Report from the panel members appointed to theEighth Joint National Committee (JNC 8). JAMA. 311(5),2014, 507-20.11. Hypertension Guidelines: Clear as Mud. Medscape. Jan 30,2014.Source of Support: Nil, Conflict of Interest: None.International Journal of Pharmaceutical Sciences Review and ResearchAvailable online at www.globalresearchonline.net Copyright protected. Unauthorised republication, reproduction, distribution, dissemination and copying of this document in whole or in part is strictly prohibited.43 Copyright pro
first guidelines (JNC-1) was published in 1977, subsequent updates were published in 3 to 6 year intervals, JNC-2 (1980), JNC-3 (1984), JNC-4 (1988), JNC-5 (1992), JNC-6 (1997), and JNC-7 (2004) and the latest edition is JNC-8 published in 2013.3 Development of JNC-8 It was commissioned by the NHLBI in 2008. Panel
JNC 1, 2 (1977, 1980) 105 JNC 3 (1984) 160 90-104 mild 105-114 moderate 115 severe JNC 6 (1997) 140-159 stage I 160-179 stage II 180 stage III 90-99 stage I 100-109 stage II 109 stage III JNC 7 (2003) 120-140 pre-HTN 140-159 stage I 160 stage II 90-99 stage I 10
The JNC 7 guidelines were a comprehensive expert consen - sus of the prevention, detection, evaluation, and treatment of high blood pressure in adults (Chobanian 2003), whereas the JNC 8 guidelines were an evidence-based, focused set of rec-ommendations. The JNC 8 panel chose three critical questions
recommendations than JNC 8. While JNC 8 suggests treating patients with both diabetes and hypertension to a blood pres-sure goal 140/90 mmHg, ADA standards of care advise treat-ing to a goal of 140/80 mmHg. The ADA also states that a lo
JNC Doublebeam is the most rigid form of welded mesh fencing available. The robust nature of its construction ensures that this twin wire mesh is difficult to deform and capable of resisting attacks of vandalism. Manufactured in panels from heavy gauge welded mesh with 200*50 aperture they are mounted on RHS type posts with the JNC fixing
complete either the Level 2 or Level 3 Certificate. Although learners can complete the Level 2 Award and not progress on to the Certificate, JNC Youth Support Worker recognition is only provided on completion of the Level 3 Certificate. While
JNC’s advanced cross-linking technologies have created more robust base beads operable at high flow and pressure. Further, Cellufine MAX ion exchange (IEX) . Fig. 7 Residence time vs. DBC for Cellufine MAX CM Column: 5 mm ID 50 mm L Tris-HCl (pH 8.5) for BSA 188 148 198 159 115 162 115
JNC 7: Lifestyle Modifications to Prevent and Manage Hypertension DASH Dietary Approaches to Stop Hypertension. Chobanian AV et al. JNC 7: . 34.7 43.8 38.1 80.6 31.0 25.5 24.6 25.3 25.2 24.9 23.8 16.9 13.9 12.8 12.6 11.8 100 90-99 80-89 75-79 70-74 70 120 120-139 140-159
anatomi tulang berdasarkan gambar berikut ini! Diaphysis: This is the long central shaft Epiphysis: Forms the larger rounded ends of long bones Metaphysis: Area betweent the diaphysis and epiphysis at both ends of the bone Epiphyseal Plates: Plates of cartilage, also known as growth plates which allow the long bones to grow in length during childhood. Once we stop growing, between 18 and 25 .
