Determining optimal strategies for primary prevention of cardiovascular disease: a synopsis of an evidence synthesis study.

Abstract

BACKGROUND

Cardiovascular disease remains a leading cause of morbidity and mortality worldwide. This series of systematic reviews and meta-analyses synthesised evidence on the effectiveness, comparative effectiveness and cost-effectiveness of pharmacological and non-pharmacological interventions for primary cardiovascular disease prevention.

METHODS

Five systematic reviews and meta-analyses were conducted using rigorous methods, including comprehensive searches, duplicate screening, risk-of-bias assessments and adherence to reporting guidelines. An umbrella review summarised evidence from 95 systematic reviews. A machine learning study developed a parallel Convolutional Neural Network algorithm with 96.4% recall and 99.1% precision for study screening. A network meta-analysis compared preventive strategies across 139 trials (1,053,772 participants). Simulation modelling projected the population impact of policy interventions, and a cost-effectiveness review appraised eight United Kingdom-based economic evaluations.

RESULTS

The umbrella review found that antiplatelets reduced major cardiovascular disease events in 8/17 meta-analyses (relative risks 0.85-0.97), while statins reduced cardiovascular disease mortality (relative risks 0.71-0.89), all-cause mortality (relative risks 0.66-0.93) and major cardiovascular disease events (relative risks 0.59-0.90). sodium-glucose transport protein 2 inhibitors reduced major cardiovascular disease events by 8% (relative risk 0.92, 95% confidence interval 0.89 to 0.95) and all-cause mortality by 6% (relative risk 0.94, 95% confidence interval 0.90 to 0.98). Non-pharmacological interventions showed limited evidence, though vitamin D (relative risks 0.93-0.94) and dietary changes (relative risk 0.91, 95% confidence interval 0.85 to 0.97) had some benefits. The network meta-analysis found that antihypertensives (relative risk 0.76, 95% confidence interval 0.64 to 0.90), intensive blood pressure control (relative risk 0.66, 95% confidence interval 0.46 to 0.96), statins (relative risk 0.81, 95% confidence interval 0.71 to 0.91) and multifactorial lifestyle interventions (relative risk 0.75, 95% confidence interval 0.61 to 0.92) significantly reduced composite cardiovascular disease events and mortality. Blood pressure lowering also reduced all-cause mortality (relative risk 0.82, 95% confidence interval 0.71 to 0.94). Simulation modelling projected substantial population-level health gains. National salt reduction programmes could prevent 1900-48,000 cardiovascular disease deaths annually, while tobacco control initiatives could avert 15,500 deaths yearly. In the United Kingdom, salt reduction could prevent 4450 deaths annually, and transfat elimination could prevent 1700-3500 deaths yearly. Cost-effectiveness analyses found most interventions had incremental cost-effectiveness ratio below £20,000-30,000 per quality-adjusted life-year. However, intensive diabetes treatment and enhanced motivational interviewing exceeded £55,000/quality-adjusted life-year, indicating low value for money.

LIMITATIONS

Limitations included residual confounding, heterogeneity in simulation models and a lack of head-to-head trials for some interventions. More research is needed on non-pharmacological interventions, policy implementation and health economic analyses.

CONCLUSIONS

This series supports antihypertensives, statins and multifactorial lifestyle interventions as core strategies for primary cardiovascular disease prevention. Policy interventions show potential for large-scale impact, and most approaches are cost-effective. Future research should prioritise head-to-head trials, implementation studies and health economic analyses to optimise prevention efforts.

FUNDING

This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number 17/148/05.

Plain language summary

We did five detailed analyses to evaluate how well different heart disease prevention methods work and if they are worth the cost: Big picture review: we summarised findings from 95 reviews on medications and lifestyle changes. Computer analysis: we developed a computer system to quickly and accurately identify relevant studies. Comparing treatments: we compared results from 139 clinical trials with over 1 million participants to rank how well different strategies work. Policy impact: we looked at 54 studies to assess how government policies like tobacco control and reducing salt in foods could affect heart disease rates. Value for money: we evaluated economic studies to see which prevention methods give the best value for money. - Medications: drugs to lower blood pressure, cholesterol and blood sugar significantly reduced heart disease events and deaths. Aspirin also helped. - Lifestyle: results were mixed. Some intensive programmes that tackled multiple risk factors at once showed promise, but evidence was limited. Supplements and changing just one lifestyle factor had little clear benefit. - Policies: programmes that reach entire populations, like reducing salt in foods and controlling tobacco, could prevent thousands of heart disease deaths each year in many countries. - Cost: most prevention approaches were a good value, but some, like intensive treatment for diabetes, were less cost-effective. Medications to control heart disease risk factors, intensive lifestyle programmes and strong government policies are all important in reducing the global burden of heart disease. More research directly comparing different strategies and looking at long-term, real-world effects is needed.

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