Nonpharmacologic Interventions for Reducing Blood Pressure in Adults With Prehypertension to Established Hypertension

Abstract

Background Nonpharmacologic interventions that modify lifestyle can lower blood pressure (BP) and have been assessed in numerous randomized controlled trials and pairwise meta-analyses. It is still unclear which intervention would be most efficacious. Methods and Results Bayesian network meta-analyses were performed to estimate the comparative effectiveness of different interventions for lowering BP. From 60 166 potentially relevant articles, 120 eligible articles (14 923 participants) with a median follow-up of 12 weeks, assessing 22 nonpharmacologic interventions, were included. According to the surface under the cumulative ranking probabilities and Grading of Recommendations Assessment, Development and Evaluation (GRADE) quality of evidence, for adults with prehypertension to established hypertension, high-quality evidence indicated that the Dietary Approach to Stop Hypertension (DASH) was superior to usual care and all other nonpharmacologic interventions in lowering systolic BP (weighted mean difference, 6.97 mm Hg; 95% credible interval, 4.50-9.47) and diastolic BP (weighted mean difference, 3.54 mm Hg; 95% credible interval, 1.80-5.28). Compared with usual care, moderate- to high-quality evidence indicated that aerobic exercise, isometric training, low-sodium and high-potassium salt, comprehensive lifestyle modification, breathing-control, and meditation could lower systolic BP and diastolic BP. For patients with hypertension, moderate- to high-quality evidence suggested that the interventions listed (except comprehensive lifestyle modification) were associated with greater systolic BP and diastolic BP reduction than usual care; salt restriction was also effective in lowering both systolic BP and diastolic BP. Among overweight and obese participants, low-calorie diet and low-calorie diet plus exercise could lower more BP than exercise. Conclusions DASH might be the most effective intervention in lowering BP for adults with prehypertension to established hypertension. Aerobic exercise, isometric training, low-sodium and high-potassium salt, comprehensive lifestyle modification, salt restriction, breathing-control, meditation and low-calorie diet also have obvious effects on BP reduction.

Keywords: hypertension; network meta‐analysis; nonpharmacologic interventions; randomized controlled trial; systematic review.

Figure 1. PRISMA flow chart of the study selection for the network meta‐analysis.

*In case of multiple publications from the same population, only the study with the largest sample size was included. For studies published more than once, only the study with the most informative and complete data was included. Any additional publications were excluded to avoid double counting data from the same trial. PRISMA indicates Preferred Reporting Items for Systematic Reviews and Meta‐analyses.

Figure 2. Network geometry used to assess the comparative effects of 22 nonpharmacologic interventions.

A, Adult with prehypertension to established hypertension. B, Patients with hypertension. The nodes represent 22 nonpharmacologic interventions and usual care. The size of every node is proportional to the number of randomly assigned participants (sample size). Each line represents a direct comparison, and the width of the lines is proportional to the number of studies comparing every pair of interventions. The coding guide, which provides a description of each intervention component, can be found in Table 1. DASH indicates Dietary Approaches to Stop Hypertension; MBSR, mindfulness‐based stress reduction; and PMR, progressive muscle relaxation.

Figure 3. Forest plots for mean changes of blood pressure in adults with prehypertension to established hypertension.

A, Systolic blood pressure. B, Diastolic blood pressure. Mean changes of blood pressure are reported in WMD and 95% CrI for intervention vs usual care. Rectangle represents the point estimate for the effect of each intervention. Horizontal lines indicate 95% CrI. Tables on the left of the forest plot show, for each intervention, the number of direct comparison studies, number of participants, rankings of SUCRA probabilities and quality of evidence. Interventions are ranked according to the rankings of SUCRA. The quality of evidence was classified as high, moderate, low, or very low. CrI indicates credible interval; DASH, Dietary Approaches to Stop Hypertension; MBSR, mindfulness‐based stress reduction; NA, not available; PMR, progressive muscle relaxation; SUCRA, surface under the cumulative ranking; and WMD, weighted mean difference.

Figure 4. Forest plots for mean changes of blood pressure in patients with hypertension.

A, Systolic blood pressure. B, Diastolic blood pressure. Mean changes of blood pressure are reported in WMD and 95% CrI for intervention vs usual care. Rectangle represent the point estimate for the effect of each intervention. Horizontal lines indicate 95% CrI. For each intervention, tables on the left of the forest plot show the number of direct comparison studies, number of participants, rankings of SUCRA probabilities, and quality of evidence. Interventions are ranked according to the rankings of SUCRA. The quality of evidence was classified as high, moderate, low, and very low. CrI indicates credible interval; DASH, Dietary Approaches to Stop Hypertension; MBSR, mindfulness‐based stress reduction; NA, not available; PMR, progressive muscle relaxation; SUCRA, surface under the cumulative ranking; and WMD, weighted mean difference.