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Multimodal Secondary Prevention Behavioral Interventions for TIA and Stroke: A Systematic Review and Meta-Analysis

Lawrence, Maggie; Pringle, Jan; Kerr, Susan; Booth, Joanne; Govan, Lindsay; Roberts, Nicola J.


Maggie Lawrence

Jan Pringle

Susan Kerr

Joanne Booth

Lindsay Govan


Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions.

Searches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines.

Twenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I2 = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I2 = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I2 = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I2 = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I2 = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I2 = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I2 = 0%, 4,053 participants).

There are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required.

Journal Article Type Article
Acceptance Date Jan 27, 2015
Online Publication Date Mar 20, 2015
Publication Date 2015
Deposit Date Aug 30, 2022
Publicly Available Date Sep 1, 2022
Journal PLOS ONE
Print ISSN 1932-6203
Publisher Public Library of Science
Peer Reviewed Peer Reviewed
Volume 10
Issue 3
Article Number e0120902
Public URL


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