Interesting bit from an interview looking into the development of the HTN guidelines in the USA from the Medscape website. It seems the definition of EBM is shifting. The pendulum of clinical knowledge is swinging back to the subjective experience of the physician, away from the objective analysis of statisticians. All good physicians know the golden mean lies somewhere in between these two extremes and perhaps it is a range which varies given the particular patient, circumstances and strength of evidence.
Interesting historical perspective of where the HTN guidelines come from and the delay in JNC 8.
Dr. Black: You asked me earlier about the JNC 8 [Joint National Committee 8], and we have enough time for me to review this for you. The JNC, which began in 1972, was a product of Mary Lasker and Elliot Richardson. The VA study showed the benefits of treating high blood pressure, and they pressured the National Heart, Lung, and Blood Institute (NHLBI) to focus on this. The NHLBI formed a committee. The first guidance was written in 1973 by 16 anonymous individuals, none of whom ever admitted that they participated in writing this document, and it was not published in the usual literature. The JNC 1, which focused on the detection, evaluation, and treatment of high blood pressure, was completed in 1976 and published in 1977. Since then, a reevaluation of this guidance has taken place every 3-5 years, the last of which was completed in 2003.
JNC 7 added the word "prevention" to detection, evaluation, and treatment of high blood pressure. I was part of the JNC 6 and JNC 7 writing committees. We completed JNC 7 in 3 months from the time we were asked to do it to the time it was presented and published. JNC 8 has been in progress close to 3 years now, and instead of 9 people, dozens of people are involved. Instead of face-to-face meetings, most of the work on JNC 8 has taken place by conference calls, with insistence that the guidelines be evidence based. "Evidence based" these days means clinical trials. At the end of the JNC 7 document, we reported where our data came from, but I have a problem with relying only on clinical trials, and I will tell you what that problem is.