Le JNC 8 est sorti… mais ce n’est pas le JNC 8 ! Nouvelles recommandations américaines pour la prise en charge de l’hypertension artérielle

During year 2013, several recommendations for the management of hypertension were published: recommendations of the French and European Societies of Hypertension and two recommendations from the USA, those from the ACC/AHA/CDC groups and those from the JNC 8. The recommendations of the JNC 8 are not, strictly speaking, the recommendations of JNC 8, since they are neither endorsed by their sponsor: the National Heart, Lung and Blood Institute (NHLBI), nor by any other supervisor. They only commit their authors. Just before the publication of the JNC 8, "competing" recommendations, jointly produced by the AHA, ACC and CDC, were jointly published in Hypertension and in the Journal of American College of Cardiology, with different preferred treatment choices and significantly different algorithms. The authors of the JNC 8 have only included in their literature review randomized controlled trials of sufficient power. Randomized controlled trials are clearly the gold standard of comparative trials in medicine, but can they summarize all the knowledge? The authors of the JNC 8 propose in subjects over 60, a therapeutic threshold and target blood pressure of 150/90mmHg. This original threshold is poorly supported by the evidence and possibly increases the risk of physicians' inertia. The issue of experts' conflicts of interest has greatly changed the rules of drafting guidelines for clinical practice. Knowing that the vast majority of clinical trials is promoted by drug industry, could guidelines be strictly without any conflict of interest? Finally, recommendations for practice should have as primary, if not unique, objective to improve the practice.