【高血壓英文課件】-Getting-Blood-Pressure-to-Goal

GettingBloodPressuretoGoalRulesofThree:3drugs3months3behaviors(Activity-Diet-ControlofTobaccoandAlcohol)3Partners(Patient–Family–Provider)GettingBloodPressuretoGoal1ThisprogramwassponsoredbytheNationalKidneyFoundationofMichigan(NKFM)andtheMichiganDepartmentofCommunityHealth(MDCH).FundingwasprovidedbyagenerousgrantfromNKFMandMDCHandvariouspharmacompanies.ContinuingMedicalEducationcreditisprovidedbyWayneStateUniversitySchoolofMedicineTheprogramwasdevelopedandpreparedby:

DianeLevine,MDWayneStateUniversitySilasNorman,MD,UniversityofMichiganRosalindPeters,PhD,RN,WayneStateUniversitySusanSteigerwalt,MD,St.JohnHospitalWithinputfromtheHypertensionExpertGroupofNKFMandtheexpertiseandcreativityofitsmemberswithspecialthankstoVelmaTheisenandLindaSmithWheelockACSW,MSBAThisprogramwassponsoredby2ConflictofInterestIndividualSpeakerstoAddtheirinformationpriortopresenting

ConflictofInterestIndividual3【高血壓英文課件】-Getting-Blood-Pressure-to-Goal4【高血壓英文課件】-Getting-Blood-Pressure-to-Goal5MajorityofUSHypertensivePatientsNotatSBPGoalof<140mmHgMajorityofUSHypertensivePa6UnacceptableBPControlRatesRequireIncreasedAwareness,MoreAggressiveTreatmentUnacceptableBPControlRates7SignificanceofHBPProblem50%ofhypertensivesareuncontrolled.UptohalfarenotreceivingpharmacologictreatmentAntihypertensivetherapycanStroke–30%CHF–40-50%CAD–10-20%CADEvents-~55%Mortality–10%~$1Billionindirectmedicalcosts/yearSignificanceofHBPProblem50%8CardiovascularMortalityRiskDoublesWithEach20/10mmHgBPIncrement*CardiovascularMortalityRisk9CV-RelatedMortalityRatesAreHigherinAfricanAmericansCV-RelatedMortalityRatesAre10CardiovascularEventsinTreatedHypertensiveDiabeticPatientsCardiovascularEventsinTreat11PreventingKidneyFailureAfricanAmericansinMichiganhavepoorerbloodpressurecontrolthanCaucasiansAfricanAmericansareatfivetimesgreaterriskofprogressiontoendstagerenaldiseaseBetterbloodpressurecontrolSLOWSPROGRESSIONofrenaldiseaseBPcontrolreducestheriskofstroke,MI,andCHFPreventingKidneyFailureAfric12FactorsContributingtoPoorBPControlPatientFactorsAgeRace/ethnicityObesityAccessNonadherenceKnowledgeCostComplextreatmentPt/ProviderCommunicationSecondaryHTNProviderFactorsMeasurementissuesLackofknowledge/DisagreementwithguidelinesConcernforsideeffectsNon-advancingofdrugsinasymptomaticpatientsResponsetopatientsconcernsovercomplexityoftreatmentLackoftimeFactorsContributingtoPoorB13MeasurementAccuracyAccuracyofofficemeasurementsManual–RegularlycalibratedWhite-CoatSyndromeHomeMonitoring

OmronHealthcareArm(notwrist)monitorGoalreadings<135/85MeasurementAccuracyAccuracyo14

MeasurementAccuracy*

PatientPosition:BacksupportedFeetonthefloorArmattheleveloftheheartNotalkingCuffSize–Mostadultsneedalargecuff(SeeCDandAHAwebsitefordetails)TaketwiceCheckorthostaticbloodpressure*CDprovidedtosupportreviewandstandardizationofBPmeasurement

MeasurementAccuracy*

Pa15MeasurementAccuracy:

OrthostaticHypotension20%prevalenceincommunitydwellingadultsoverage65IncreaseswithagePresentinyoungerpatientswithdiabetesorautonomicdysfunction“Iforthostasiscannotbecorrected,usestandingBPtoassessgoalBP”(JNC-7)MeasurementAccuracy:

Orthosta16JNC7:NewBPClassificationsJNC7:NewBPClassifications17JNC7RecommendedBPGoals<140and<90mmHg

Patientswithmostconditions<130and<80mmHgDiabetesMellitusCKDAlbuminuria>300mg/24hror>200mg/gurinarycreatinineeGFR<60ml/min/1.73m2SerumcreatininelevelsaloneoverestimatekidneyfunctionAssessandaddressothercardiovascularriskfactorsChobanianAVetal.JAMA.2003;289:2560-2572.JNC7RecommendedBPGoals<14018JNC7:ManagementofHypertensionbyBPClassificationJNC7:ManagementofHypertens19CommonProviderConcernswithGuidelineGoals

NonAcceptanceofBPgoalsResistancetoacceptSBPthresholdsNottreatingunlessSBP>160mmHgConcernsofincreasedcardiovascularriskwithexcessiveloweringofDBP(J-Curve)BelievethatmoretimeisneededtoreachgoalVALUE,

LANCET,2004:363:2022-2031CommonProviderConcernswith20Ruleof3

“MDBP”3

Months3

Drugs3

Behaviors

(activity-diet-alcoholandtobaccocontrol)3

Partners

(Patient–Family–Provider)Ruleof3

“MDBP”3Months21

ItMightTake3MonthsGettingBPtogoalin3monthsRequiresmultiplevisitsGettingtoGoalvisitschedule:MonthlyuntilgoalisreachedIncreasevisitfrequencyifStage2Increasevisitfrequencywithcomorbidconditions

Atgoal–followupvisitscheduleEvery3-6monthsdependingoncomorbiditiesCheckK+andCreatinine1-2x/year

ItMightTake3MonthsGetting22

DrugTherapyStepApproach:StartwithdiureticifnocontraindicationsAddACEICalciumChannelBlocker(CCB)Betablockers–butcautionMostpatientsrequire

multipledrugstoachievecontrol(average=3.5drugs)Usemultipledrugsif:BP20/10mmHgabovegoal(Stage22drugs)StandingBPabovegoalinpatientsoverage65orDMNotatgoalafter3months

DrugTherapyStepApproach:23MultipleAntihypertensiveAgentsAreNeededtoAchieveTargetBloodPressureMultipleAntihypertensiveAgen24DrugTreatment:DiureticsIfnocompellingindications(CHF,diabetes,CKD)Chlorthalidone(orotherthiazides)firstThenACEIorARBRememberBetaBlockersARENOTforprimarypreventionandareinferiortodiureticsasmonotherapyVigilantlypreventhypokalemiaSpironolactone/HCTZisagreatcombination!BringpatientsbackinoneweektocheckfordiureticinducedhypokalemiaWatchforhyponatremiaDrugTreatment:DiureticsIfno25DrugTreatment:ACEinhibitorsCheckElectrolytes,BUN,andCreatininepriortostartingRecheckK+andCreatinine1weekafterinitiationoftherapyGenericavailableBIDDosing:enalapril(5mgbid-20mgbid)captopril(12.5mgbid-50mgbid)DailyDosinglisinopril(5-40mgdaily)Sideeffects:Cough-switchtoARBifaffordableHyperkalemiaandacuterenalfailureAngioedemaDrugTreatment:ACEinhibitors26WhatHaveWeLearned?

TreatmentTreatmentoftheveryelderlydecreases strokeandCADbutdoesnotprolongsurvival(Lancet1999:353:793)Bestdrugsinrankorder:ChlorthalidoneACEinhibitorHCTZ(Hypertension2004;44:800)CCB

WhatHaveWeLearned?

Treatme27WhatHaveWeLearned?

TreatmentACEIandARBdecreasenewonsetofdiabetesby25%comparedtobetablockers(LIFE);23%comparedtoCCBs(VALUEtrial)NewonsetofdiabeteswhileundergoingtreatmentforhypertensionconfersthesameexcessCVriskaspreexistingdiabetes(Hypertension(2004)43p.963)WhatHaveWeLearned?

Treatme28WhatHaveWeLearned?

TreatmentMonotherapywithatenololisNOTasefficaciousasotherantihypertensivesfordecreasingCVriskdespiteequivalentBPcontrol(Lancet:2004:364:1684)BetablockersareinferiortodiureticsforbloodpressurecontrolandCVriskprotection(stroke,CHF)inolderpatients(MRCtrial,1990;JAMA

1998;279:1903-1907;INVEST:JAMA290:2805-2816;ASCOTTrial)WhatHaveWeLearned?

Treatme29CombinationTreatmentsLogical/additivecombinationsDiuretic+ACEIorARBDiuretic+BetaBlockerorsympatholyticsCCB+ACEIorARBDiuretic+BetaBlocker+vasodilatorDiuretic+CCBCombinationTreatmentsLogical30CombinationTreatmentsCombinationswithNOadditiveeffectBetaBlocker+ACEIVasodilators+CCBCombinationwithadditivesideeffectsBetaBlocker+clonidineorguanfacineBetaBlocker+verapamilordiltiazemClonidine/guanfacine+verapamilordiltiazemCombinationTreatmentsCombinat31Whenadding

Indifficulttocontrolpatients

ItTakes3DRUGS!ChoosealogicalADDITIVEcombinations:Diuretic+ACEI+CCBDiuretic+BBlocker+vasodilatorDiuretic+clonidine+vasodilatorWhenadding

32SpecialPopulationsDiabetesACEIorARBDiureticsareimportantadjuncttherapyBScontrolassociatedwithBPcontrolCKDACEIorARBareimportanttopreserverenalfunctionIfeGFR<50starttorsemideorfurosemidebidPostMIBetablockersACEIorARBCheckK+andCreatininepriortoinitiatingand1weekafterinitiatingACESpecialPopulationsDiabetes33

ItMightTake3MonthsButifnotatgoalby6monthsconsider:PatientreasonsfornonadherenceSleepApneaAlcoholoveruseDiabetesChronicKidneyDiseaseSecondarycausesConsultwithorrefertoHypertensionSpecialist

VALUE,LANCET,2004:363:2022-2031

ItMightTake3MonthsButif34SleepApneaUpto60%maleswithresistanthypertension(alsocommoninpostmenopausalfemales)Suspectdiagnosis-screenandreferPathophysiologyofhypertensionlikelySNSactivationSleepApneaUpto60%maleswit35

Lifestyle:ItTakes3BEHAVIORSExerciseDietControloftobaccoandalcohol

Lifestyle:ItTakes3BEHAVIO36Lifestyle:Exercise4-9mmHgSBPreduction30-45minutes/day/5-7days/weekAerobicactivity(e.g.briskwalking)WriteaprescriptionFavoritePatientSig40minutesofwalking5X/wk BPMD3333Lifestyle:Exercise4-9mmHgSBP37Lifestyle:DietWeightControl

5-20mmHgSBPreduction/10kgLowSodium(<2.4g)

2-8mmHgSBPreductionDASH8-14mmHgSBPreductionLifestyle:DietWeightControl38ControlofTobaccoandAlcoholSmokingCessationWriteprescriptionAlcoholModeration<2alcoholicdrinks/day–men<1alcoholicdrink/day–women2-4mmHgreductioninSBPAccessforothersubstancesControlofTobaccoandAlcohol39Partners:Ittakes3PartnersPatientFamilyProviderProvider/PatientRelationshipKeyPartners:Ittakes3PartnersP40ThePatient:Participationiscrucial

Describethejourney“Thisisaseriousdisease”“Iwillneedtoseeyouevery4-6weeks”“Thisisyourgoal<140/90(or130/80)”“Achievingyourgoalisimportantbecauseitlowersyourriskof…Sharegoalsetting“Let’ssetsomegoals“Thishowcanyouhelp“Whatareyouwillingtodo?“Weareateam—Patient,provider,“family”Ifwedonotachieveyourgoals…ThePatient:Participationis41Partners:PatientsPatientnon-adherencetotherapyLackofconcernifasymptomaticFeel“better”withhigherBPDon’tworryabout“touch”ofhighBPMistrustofhealthcareprovidersandhealthcaresystemImprovedadherencewithIncreasedcontactwithprovidersSelf/homeBPmeasurement-OMRONarm,usuallyLARGEADULTcuff(Bladderencircling80%arm)Useofpatientrecordtokeeptrackofinfluenceoffactors(e.g.diet)onBPPartners:PatientsPatientnon-42Partners:

“Family”,Friends,CommunityInvolve“family”wheneverpossibleEssentialforlifestylemodificationBefamiliarwithcommunityresourcesPartners:

“Family”,Friends,43Partners:ProvidersFollowJNCandMQIC*GuidelinesDocumentGoalSchedulefrequentvisitstogettogoal

3monthstogoal!!!!ToolstogettogoaleGFRslideruletoassessrenalfunctionCollaborativepracticewithAPNsimprovescontrol*www.MQIC.orgPartners:ProvidersFollowJNC44ProviderStepsto

IncreaseAdherenceWritelifestyleprescriptionsConsidercostsofdrugs–genericswheneverpossibleSimplifydrugregimensDailytherapyorBIDAddresspatient’sunderstandingofthediseaseanditstreatmentTelephonefollowupsincreaseadherenceespeciallyfor“noshows”trytokeepthemintreatmentAdditionalfollowupasnegotiatedwithpatientOfficeRNorAPNwillincreaseBPcontrol(CollaborativePractice)ProviderStepsto

IncreaseAd45KeyPointsfromPresentation

MeasurementAccuracyisimportantDetermineGoalBP<140/90<130/80DMCKDFollowguidelinesRulesof3(MDBP)3

Months3

Drugs3

Behaviors3

PartnersKeyPointsfromPresentationM46HandoutsInformationcontainedonCDTonight’sslidepresentation–sharewithcolleaguesBPmeasurementprotocolMQICguidelinesNHLBIDASHdietinformationPatientHealthRecordPrescriptionpadsforexercise/lifestyleprescriptionsHandoutsInformationcontained47Questions?

Casesyou’dliketodiscuss?Questions?

Casesyou’dliket48GettingBloodPressuretoGoalRulesofThree:3drugs3months3behaviors(Activity-Diet-ControlofTobaccoandAlcohol)3Partners(Patient–Family–Provider)GettingBloodPressuretoGoal49ThisprogramwassponsoredbytheNationalKidneyFoundationofMichigan(NKFM)andtheMichiganDepartmentofCommunityHealth(MDCH).FundingwasprovidedbyagenerousgrantfromNKFMandMDCHandvariouspharmacompanies.ContinuingMedicalEducationcreditisprovidedbyWayneStateUniversitySchoolofMedicineTheprogramwasdevelopedandpreparedby:

DianeLevine,MDWayneStateUniversitySilasNorman,MD,UniversityofMichiganRosalindPeters,PhD,RN,WayneStateUniversitySusanSteigerwalt,MD,St.JohnHospitalWithinputfromtheHypertensionExpertGroupofNKFMandtheexpertiseandcreativityofitsmemberswithspecialthankstoVelmaTheisenandLindaSmithWheelockACSW,MSBAThisprogramwassponsoredby50ConflictofInterestIndividualSpeakerstoAddtheirinformationpriortopresenting

ConflictofInterestIndividual51【高血壓英文課件】-Getting-Blood-Pressure-to-Goal52【高血壓英文課件】-Getting-Blood-Pressure-to-Goal53MajorityofUSHypertensivePatientsNotatSBPGoalof<140mmHgMajorityofUSHypertensivePa54UnacceptableBPControlRatesRequireIncreasedAwareness,MoreAggressiveTreatmentUnacceptableBPControlRates55SignificanceofHBPProblem50%ofhypertensivesareuncontrolled.UptohalfarenotreceivingpharmacologictreatmentAntihypertensivetherapycanStroke–30%CHF–40-50%CAD–10-20%CADEvents-~55%Mortality–10%~$1Billionindirectmedicalcosts/yearSignificanceofHBPProblem50%56CardiovascularMortalityRiskDoublesWithEach20/10mmHgBPIncrement*CardiovascularMortalityRisk57CV-RelatedMortalityRatesAreHigherinAfricanAmericansCV-RelatedMortalityRatesAre58CardiovascularEventsinTreatedHypertensiveDiabeticPatientsCardiovascularEventsinTreat59PreventingKidneyFailureAfricanAmericansinMichiganhavepoorerbloodpressurecontrolthanCaucasiansAfricanAmericansareatfivetimesgreaterriskofprogressiontoendstagerenaldiseaseBetterbloodpressurecontrolSLOWSPROGRESSIONofrenaldiseaseBPcontrolreducestheriskofstroke,MI,andCHFPreventingKidneyFailureAfric60FactorsContributingtoPoorBPControlPatientFactorsAgeRace/ethnicityObesityAccessNonadherenceKnowledgeCostComplextreatmentPt/ProviderCommunicationSecondaryHTNProviderFactorsMeasurementissuesLackofknowledge/DisagreementwithguidelinesConcernforsideeffectsNon-advancingofdrugsinasymptomaticpatientsResponsetopatientsconcernsovercomplexityoftreatmentLackoftimeFactorsContributingtoPoorB61MeasurementAccuracyAccuracyofofficemeasurementsManual–RegularlycalibratedWhite-CoatSyndromeHomeMonitoring

OmronHealthcareArm(notwrist)monitorGoalreadings<135/85MeasurementAccuracyAccuracyo62

MeasurementAccuracy*

PatientPosition:BacksupportedFeetonthefloorArmattheleveloftheheartNotalkingCuffSize–Mostadultsneedalargecuff(SeeCDandAHAwebsitefordetails)TaketwiceCheckorthostaticbloodpressure*CDprovidedtosupportreviewandstandardizationofBPmeasurement

MeasurementAccuracy*

Pa63MeasurementAccuracy:

OrthostaticHypotension20%prevalenceincommunitydwellingadultsoverage65IncreaseswithagePresentinyoungerpatientswithdiabetesorautonomicdysfunction“Iforthostasiscannotbecorrected,usestandingBPtoassessgoalBP”(JNC-7)MeasurementAccuracy:

Orthosta64JNC7:NewBPClassificationsJNC7:NewBPClassifications65JNC7RecommendedBPGoals<140and<90mmHg

Patientswithmostconditions<130and<80mmHgDiabetesMellitusCKDAlbuminuria>300mg/24hror>200mg/gurinarycreatinineeGFR<60ml/min/1.73m2SerumcreatininelevelsaloneoverestimatekidneyfunctionAssessandaddressothercardiovascularriskfactorsChobanianAVetal.JAMA.2003;289:2560-2572.JNC7RecommendedBPGoals<14066JNC7:ManagementofHypertensionbyBPClassificationJNC7:ManagementofHypertens67CommonProviderConcernswithGuidelineGoals

NonAcceptanceofBPgoalsResistancetoacceptSBPthresholdsNottreatingunlessSBP>160mmHgConcernsofincreasedcardiovascularriskwithexcessiveloweringofDBP(J-Curve)BelievethatmoretimeisneededtoreachgoalVALUE,

LANCET,2004:363:2022-2031CommonProviderConcernswith68Ruleof3

“MDBP”3

Months3

Drugs3

Behaviors

(activity-diet-alcoholandtobaccocontrol)3

Partners

(Patient–Family–Provider)Ruleof3

“MDBP”3Months69

ItMightTake3MonthsGettingBPtogoalin3monthsRequiresmultiplevisitsGettingtoGoalvisitschedule:MonthlyuntilgoalisreachedIncreasevisitfrequencyifStage2Increasevisitfrequencywithcomorbidconditions

Atgoal–followupvisitscheduleEvery3-6monthsdependingoncomorbiditiesCheckK+andCreatinine1-2x/year

ItMightTake3MonthsGetting70

DrugTherapyStepApproach:StartwithdiureticifnocontraindicationsAddACEICalciumChannelBlocker(CCB)Betablockers–butcautionMostpatientsrequire

multipledrugstoachievecontrol(average=3.5drugs)Usemultipledrugsif:BP20/10mmHgabovegoal(Stage22drugs)StandingBPabovegoalinpatientsoverage65orDMNotatgoalafter3months

DrugTherapyStepApproach:71MultipleAntihypertensiveAgentsAreNeededtoAchieveTargetBloodPressureMultipleAntihypertensiveAgen72DrugTreatment:DiureticsIfnocompellingindications(CHF,diabetes,CKD)Chlorthalidone(orotherthiazides)firstThenACEIorARBRememberBetaBlockersARENOTforprimarypreventionandareinferiortodiureticsasmonotherapyVigilantlypreventhypokalemiaSpironolactone/HCTZisagreatcombination!BringpatientsbackinoneweektocheckfordiureticinducedhypokalemiaWatchforhyponatremiaDrugTreatment:DiureticsIfno73DrugTreatment:ACEinhibitorsCheckElectrolytes,BUN,andCreatininepriortostartingRecheckK+andCreatinine1weekafterinitiationoftherapyGenericavailableBIDDosing:enalapril(5mgbid-20mgbid)captopril(12.5mgbid-50mgbid)DailyDosinglisinopril(5-40mgdaily)Sideeffects:Cough-switchtoARBifaffordableHyperkalemiaandacuterenalfailureAngioedemaDrugTreatment:ACEinhibitors74WhatHaveWeLearned?

TreatmentTreatmentoftheveryelderlydecreases strokeandCADbutdoesnotprolongsurvival(Lancet1999:353:793)Bestdrugsinrankorder:ChlorthalidoneACEinhibitorHCTZ(Hypertension2004;44:800)CCB

WhatHaveWeLearned?

Treatme75WhatHaveWeLearned?

TreatmentACEIandARBdecreasenewonsetofdiabetesby25%comparedtobetablockers(LIFE);23%comparedtoCCBs(VALUEtrial)NewonsetofdiabeteswhileundergoingtreatmentforhypertensionconfersthesameexcessCVriskaspreexistingdiabetes(Hypertension(2004)43p.963)WhatHaveWeLearned?

Treatme76WhatHaveWeLearned?

TreatmentMonotherapywithatenololisNOTasefficaciousasotherantihypertensivesfordecreasingCVriskdespiteequivalentBPcontrol(Lancet:2004:364:1684)BetablockersareinferiortodiureticsforbloodpressurecontrolandCVriskprotection(stroke,CHF)inolderpatients(MRCtrial,1990;JAMA

1998;279:1903-1907;INVEST:JAMA290:2805-2816;ASCOTTrial)WhatHaveWeLearned?

Treatme77CombinationTreatmentsLogical/additivecombinationsDiuretic+ACEIorARBDiuretic+BetaBlockerorsympatholyticsCCB+ACEIorARBDiuretic+BetaBlocker+vasodilatorDiuretic+CCBCombinationTreatmentsLogical78CombinationTreatmentsCombinationswithNOadditiveeffectBetaBlocker+ACEIVasodilators+CCBCombinationwithadditivesideeffectsBetaBlocker+clonidineorguanfacineBetaBlocker+verapamilordiltiazemClonidine/guanfacine+verapamilordiltiazemCombinationTreatmentsCombinat79Whenadding

Indifficulttocontrolpatients

ItTakes3DRUGS!ChoosealogicalADDITIVEcombinations:Diuretic+ACEI+CCBDiuretic+BBlocker+vasodilatorDiuretic+clonidine+vasodilatorWhenadding

80SpecialPopulationsDiabetesACEIorARBDiureticsareimportantadjuncttherapyBScontrolassociatedwithBPcontrolCKDACEIorARBareimportanttopreserverenalfunctionIfeGFR<50starttorsemideorfurosemidebidPostMIBetablockersACEIorARBCheckK+andCreatininepriortoinitiatingand1weekafterinitiatingACESpecialPopulationsDiabetes81

ItMightTake3MonthsButifnotatgoalby6monthsconsider:PatientreasonsfornonadherenceSleepApneaAlcoholoveruseDiabetesChronicKidneyDiseaseSecondarycausesConsultwithorrefertoHypertensionSpecialist

VALUE,LANCET,2004:363:2022-2031

ItMightTake3MonthsButif82SleepApneaUpto60%maleswithresistanthypertension(alsocommoninpostmenopausalfemales)Suspectdiagnosis-screenandreferPathophysiologyofhypertensionlikelySNSactivationSleepApneaUpto60%maleswit83

Lifestyle:ItTakes3BEHAVIORSExerciseDietControloftobaccoandalcohol

Lifestyle:ItTakes3BEHAVIO84Lifestyle:Exercise4-9mmHgSBPreduction30-45minutes/day/5-7days/weekAerobicactivity(e.g.briskwalking)WriteaprescriptionFavoritePatientSig40minutesofwalking5X/wk BPMD3333Lifestyle:Exercise4-9mmHgSBP85Lifestyle:DietWeightControl

5-20mmHgSBPreduction/10kgLowSodium(<2.4g)

2-8mmHgSBPreductionDASH8-14mmHgSBPreductionLifestyle:DietWeightControl86ControlofTobaccoandAlcoholSmokingCessationWriteprescriptionAlcoholModeration<2alcoholicdrinks/day–men<1alcoholicdrink/day–women2-4mmHgreductioninSBPAccessforothersubstancesControlofTobaccoandAlcohol87Partners:Ittakes3PartnersPatientFamilyProviderProvider/Pa