Multiple risk factor interventions for primary prevention of coronary heart disease

Shah Ebrahim; Andrew Beswick; Margaret Burke; George Davey Smith

doi:10.1002/14651858.CD001561.pub2

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Analysis 1.1

Comparison 1 Multiple risk factor intervention versus control, Outcome 1 Total mortality.

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Analysis 1.2

Comparison 1 Multiple risk factor intervention versus control, Outcome 2 Coronary heart disease mortality.

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Analysis 1.3

Comparison 1 Multiple risk factor intervention versus control, Outcome 3 Systolic blood pressure.

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Analysis 1.4

Comparison 1 Multiple risk factor intervention versus control, Outcome 4 Diastolic blood pressure.

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Analysis 1.5

Comparison 1 Multiple risk factor intervention versus control, Outcome 5 Blood cholesterol.

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Analysis 1.6

Comparison 1 Multiple risk factor intervention versus control, Outcome 6 Smoking prevalence.

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Analysis 1.7

Comparison 1 Multiple risk factor intervention versus control, Outcome 7 Systolic blood pressure (individual analysis or cluster).

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Analysis 1.8

Comparison 1 Multiple risk factor intervention versus control, Outcome 8 Diastolic blood pressure (individual analysis or cluster).

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Analysis 1.9

Comparison 1 Multiple risk factor intervention versus control, Outcome 9 Cholesterol (individual analysis or cluster).

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Analysis 1.10

Comparison 1 Multiple risk factor intervention versus control, Outcome 10 Smoking prevalence (individual analysis or cluster).

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Table 1. MEDLINE search strategy April 1995

randomized controlled trial.pt.
randomized controlled trials/
random‐allocation.sh.
double‐blind‐method.sh.
single‐blind‐method.sh.
1 or 2 or 3 or 4 or 5
clinical trials.pt.
clinical trials.sh.
clin$ near trial$.ti.
clin$ near trial$.ab.
placebo.sh.
placebo.tw.
random.tw.
7 or 8 or 9 or 10 or 11 or 12 or 13
limit 14 to human
coronary disease.sh.
cerebrovascular disorders.sh.

Table 1. MEDLINE search strategy April 1995

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Table 2. CENTRAL search strategy Issue 3 2001

#1 CARDIOVASCULAR DISEASES
#2 CORONARY DISEASE
#3 cardiovascular
#4 (coronary near disease*)
#5 (heart near disease*)
#6 HYPERTENSION
#7 hypertension
#8 (atherosclerosis or arteriosclerosis)
#9 (hyperlipidaemia or hyperlipidemia)
#10 ARTERIOSCLEROSIS
#11 CHOLESTEROL
#12 HYPERLIPIDEMIA
#13 cholesterol
#14 (multiple next risk next factor*)
#15 (coronary next risk next factor*)
#16 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10)
#17 (#11 or #12 or #13 or #14 or #15)
#18 (#16 or #17)
#19 HEALTH EDUCATION
#20 HEALTH PROMOTION
#21 HEALTH BEHAVIOR
#22 PRIMARY PREVENTION
#23 COUNSELING
#24 counsel*
#25 (health near educat*)
#26 (patient near educat*)
#27 (education* near program*)
#28 (health near promotion*)
#29 (health near behaviour*)
#30 (health near behavior*)
#31 (primary next prevention)
#32 ((multiple next risk) near intervention*)
#33 (multifactor* near intervention*)
#34 (multifactor* near prevention)
#35 ((risk next factor*) near reduc*)
#36 ((risk next factor*) near manag*)
#37 ((risk next factor*) near intervent*)
#38 (lifestyle near intervention*)
#39 (lifestyle near advice)
#40 (life‐style near intervention*)
#41 (life‐style near advice)
#42 (life‐style near alter*)
#43 (lifestyle near alter*)
#44 (lifestyle near educat*)
#45 (life‐style near educat*)
#46 (life‐style near chang*)
#47 (lifestyle near chang*)
#48 (behavior* near chang*)
#49 (behaviour* near chang*)
#50 ((health next care) near advice)
#51 (healthcare near advice)
#52 nonpharmacologic*
#53 non‐pharmacologic*
#54 (#19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29)
#55 (#30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39)
#56 (#40 or #41 or #42 or #43 or #44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #52 or #53)
#57 ((#54 or #55 or #56)
#58 (#18 and #57)

Table 2. CENTRAL search strategy Issue 3 2001

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Table 3. MEDLINE search strategy September 2001

Database: Medline <Mid 1998 to August Week 2 2001>
Search Strategy:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
1 cardiovascular diseases/
2 exp coronary disease/
3 hypertension/
4 exp Arteriosclerosis/
5 exp Hyperlipidemia/
6 (cardiovascular adj3 disease$).tw.
7 (cardiovascular adj3 (fit or fitness)).tw.
8 (Coronary adj3 disease$).tw.
9 heart disease$.tw.
10 hypertension.tw.
11 hyperlipid?emia.tw.
12 cholesterol.tw.
13 atherosclerosis.tw.
14 arteriosclerosis.tw.
15 coronary risk factor$.tw.
16 multiple risk factor$.tw.
17 cardiovascular risk factor$.tw.
18 or/1‐17
19 health promotion/
20 exp health education/
21 exp health behavior/
22 exp counseling/
23 primary prevention/
24 (multifactor$ adj5 (intervent$ or prevent$)).tw.
25 ((lifestyle or life‐style) adj3 (intervention$ or educat$ or advice$ or alter$ or change$)).tw.
26 ((lifestyle or life‐style or behavio?r$) adj3 (intervention$ or educat$ or advice$ or alter$ or change$)).tw.
27 ((healthcare or health care) adj3 advice).tw.
28 primary prevention.tw.
29 (risk factor$ adj3 (reduc$ or manage$ or managing or intervent$ or program$)).tw.
30 (educat$ adj3 (program$ or patient$)).tw.
31 ((health or healthcare or health care) adj3 (educat$ or advice or promot$)).tw.
32 (nonpharmacologic$ or non‐pharmacologic$).tw.
33 ((lifestyle or life style or life‐style or behavio?r$ or risk factor$) adj3 modif$).tw.
34 or/19‐33
35 18 and 34
36 randomized controlled trial.pt.
37 controlled clinical trial.pt.
38 Randomized controlled trials/
39 random allocation.sh.
40 double blind method.sh.
41 single‐blind method.sh.
42 or/36‐41
43 (animal not human).sh.
44 42 not 43
45 clinical trial.pt.
46 exp Clinical trials/
47 (clin$ adj25 trial$).ti,ab.
48 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab.
49 placebos.sh.
50 placebo$.ti,ab.
51 random$.ti,ab.
52 research design.sh.
53 or/45‐52
54 53 not 43
55 54 not 44
56 44 or 54
57 35 and 56
58 limit 57 to yr=2000‐2001

Table 3. MEDLINE search strategy September 2001

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Table 4. EMBASE search strategy September 2001

Database: EMBASE <1996 to August Week 2 2001>
Search Strategy:
‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐
1 cardiovascular diseases/
2 exp coronary disease/
3 hypertension/
4 exp Arteriosclerosis/
5 exp Hyperlipidemia/
6 (cardiovascular adj3 disease$).tw.
7 (cardiovascular adj3 (fit or fitness)).tw.
8 (Coronary adj3 disease$).tw.
9 heart disease$.tw.
10 hypertension.tw.
11 hyperlipid?emia.tw.
12 cholesterol.tw.
13 atherosclerosis.tw.
14 arteriosclerosis.tw.
15 coronary risk factor$.tw.
16 multiple risk factor$.tw.
17 cardovascular risk factor$.tw.
18 or/1‐17
19 health promotion/
20 exp health education/
21 exp health behavior/
22 exp counseling/
23 primary prevention/
24 (multifactor$ adj5 (intervent$ or prevent$)).tw.
25 ((lifestyle or life‐style) adj3 (intervention$ or educat$ or advice$ or alter$ or change$)).tw.
26 ((lifestyle or life‐style or behavio?r$) adj3 (intervention$ or educat$ or advice$ or alter$ or change$)).tw.
27 ((healthcare or health care) adj3 advice).tw.
28 primary prevention.tw.
29 (risk factor$ adj3 (reduc$ or manage$ or managing or intervent$ or program$)).tw.
30 (educat$ adj3 (program$ or patient$)).tw.
31 ((health or healthcare or health care) adj3 (educat$ or advice or promot$)).tw.
32 (nonpharmacologic$ or non‐pharmacologic$).tw.
33 ((lifestyle or life style or life‐style or behavio?r$ or risk factor$) adj3 modif$).tw.
34 or/19‐33
35 18 and 34
36 cardiovascular disease/
37 exp ischemic heart disease/
38 (coronary adj3 disease$).tw.
39 heart disease$.tw.
40 Hypertension/
41 hypertension.tw.
42 (cardiovascular adj3 (disease$ or fit of fitness)).tw.
43 exp arteriosclerosis/
44 exp hyperlipidemia/
45 hyperlipid?emia.tw.
46 cholesterol.tw.
47 arteriosclero$.tw.
48 atherosclero$.tw.
49 coronary risk factor$.tw.
50 multiple risk factor$.tw.
51 cardiovascular risk factor$.tw.
52 or/36‐51
53 exp health education/
54 exp health behavior/
55 primary prevention/
56 exp counseling/
57 (multifactor$ adj5 (intervent$ or prevent$)).tw.
58 ((life‐style or life style or lifestyle or healthcare or health care) adj3 (intervention$ or educat$ or advice or alter$ or change$)).tw.
59 primary prevention.tw.
60 (risk factor$ adj3 (reduc$ or manage$ or managing or intervent$ or program$)).tw.
61 (educat$ adj3 (program$ or patient$)).tw.
62 (non pharmacologic$ or nonpharmacologic$).tw.
63 (risk factor$ adj3 modif$).tw.
64 ((lifestyle or life‐style or life style) adj3 modif$).tw.
65 exp behavior therapy/
66 (behavi?r$ adj3 (intervention$ or program$ or modif$ or change$ or alter$)).tw.
67 (promot$ adj3 (health or healthcare or health care)).tw.
68 or/53‐67
69 52 and 68
70 random$.tw.
71 randomized controlled trial/
72 trial$.tw.
73 compar$.tw.
74 follow‐up.tw.
75 blind$.tw.
76 double blind procedure/
77 placebo$.tw.
78 placebo/
79 doubl$.tw.
80 nonhuman/ not human/
81 exp child/ not exp adult/
82 or/70‐79
83 82 and 69
84 83 not (80 or 81)

Table 4. EMBASE search strategy September 2001

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Comparison 1. Multiple risk factor intervention versus control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total mortality Show forest plot	9	125167	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.96 [0.92, 1.01]

2 Coronary heart disease mortality Show forest plot	9	125167	Peto Odds Ratio (Peto, Fixed, 95% CI)	0.96 [0.89, 1.04]

3 Systolic blood pressure Show forest plot	38	53872	Mean Difference (IV, Fixed, 95% CI)	‐3.62 [‐3.93, ‐3.31]

4 Diastolic blood pressure Show forest plot	39	64859	Mean Difference (IV, Fixed, 95% CI)	‐2.76 [‐2.93, ‐2.59]

5 Blood cholesterol Show forest plot	35	66106	Mean Difference (IV, Fixed, 95% CI)	‐0.07 [‐0.08, ‐0.06]

6 Smoking prevalence Show forest plot	15	48948	Odds Ratio (M‐H, Random, 95% CI)	0.81 [0.70, 0.94]

7 Systolic blood pressure (individual analysis or cluster) Show forest plot	38	53872	Mean Difference (IV, Random, 95% CI)	‐2.68 [‐3.64, ‐1.72]

7.1 Cluster randomisation ‐ analysis by cluster	2	19355	Mean Difference (IV, Random, 95% CI)	0.56 [‐2.26, 3.38]
7.2 Individual randomisation	32	33157	Mean Difference (IV, Random, 95% CI)	‐3.24 [‐4.16, ‐2.31]
7.3 Cluster randomisation ‐ analysis by individual	4	1360	Mean Difference (IV, Random, 95% CI)	0.03 [‐3.28, 3.34]
8 Diastolic blood pressure (individual analysis or cluster) Show forest plot	39	65362	Mean Difference (IV, Random, 95% CI)	‐2.01 [‐2.63, ‐1.39]

8.1 Cluster randomisation ‐ analysis by cluster	2	19348	Mean Difference (IV, Random, 95% CI)	‐0.27 [‐0.81, 0.27]
8.2 Individual randomisation	34	44619	Mean Difference (IV, Random, 95% CI)	‐2.33 [‐2.94, ‐1.72]
8.3 Cluster randomisation ‐ analysis by individual	4	1395	Mean Difference (IV, Random, 95% CI)	‐0.00 [‐1.07, 1.07]
9 Cholesterol (individual analysis or cluster) Show forest plot	35	66106	Mean Difference (IV, Random, 95% CI)	‐0.25 [‐0.35, ‐0.15]

9.1 Cluster randomisation ‐ analysis by cluster	2	18833	Mean Difference (IV, Random, 95% CI)	0.01 [‐0.03, 0.05]
9.2 Individual randomisation	30	46775	Mean Difference (IV, Random, 95% CI)	‐0.29 [‐0.40, ‐0.18]
9.3 Cluster randomisation (analysis by individual)	3	498	Mean Difference (IV, Random, 95% CI)	0.06 [‐0.15, 0.28]
10 Smoking prevalence (individual analysis or cluster) Show forest plot	15	48948	Odds Ratio (M‐H, Random, 95% CI)	0.81 [0.70, 0.94]

10.1 Cluster randomisation ‐ analysis by cluster	1	520	Odds Ratio (M‐H, Random, 95% CI)	0.43 [0.28, 0.64]
10.2 Individual randomisation	12	29508	Odds Ratio (M‐H, Random, 95% CI)	0.82 [0.70, 0.95]
10.3 Cluster randomisation ‐ analysis by individual	2	18920	Odds Ratio (M‐H, Random, 95% CI)	0.99 [0.90, 1.08]

Comparison 1. Multiple risk factor intervention versus control

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