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Secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis: a network meta-analysis.
Plaz Torres, MC, Best, LM, Freeman, SC, Roberts, D, Cooper, NJ, Sutton, AJ, Roccarina, D, Benmassaoud, A, Iogna Prat, L, Williams, NR, et al
The Cochrane database of systematic reviews. 2021;(3):CD013122
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BACKGROUND Approximately 40% to 95% of people with cirrhosis have oesophageal varices. About 15% to 20% of oesophageal varices bleed in about one to three years of diagnosis. Several different treatments are available, which include endoscopic sclerotherapy, variceal band ligation, beta-blockers, transjugular intrahepatic portosystemic shunt (TIPS), and surgical portocaval shunts, among others. However, there is uncertainty surrounding their individual and relative benefits and harms. OBJECTIVES To compare the benefits and harms of different initial treatments for secondary prevention of variceal bleeding in adults with previous oesophageal variceal bleeding due to decompensated liver cirrhosis through a network meta-analysis and to generate rankings of the different treatments for secondary prevention according to their safety and efficacy. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until December 2019 to identify randomised clinical trials in people with cirrhosis and a previous history of bleeding from oesophageal varices. SELECTION CRITERIA We included only randomised clinical trials (irrespective of language, blinding, or status) in adults with cirrhosis and previous history of bleeding from oesophageal varices. We excluded randomised clinical trials in which participants had no previous history of bleeding from oesophageal varices, previous history of bleeding only from gastric varices, those who failed previous treatment (refractory bleeding), those who had acute bleeding at the time of treatment, and those who had previously undergone liver transplantation. DATA COLLECTION AND ANALYSIS We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the differences in treatments using hazard ratios (HR), odds ratios (OR) and rate ratios with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance. MAIN RESULTS We included a total of 48 randomised clinical trials (3526 participants) in the review. Forty-six trials (3442 participants) were included in one or more comparisons. The trials that provided the information included people with cirrhosis due to varied aetiologies. The follow-up ranged from two months to 61 months. All the trials were at high risk of bias. A total of 12 interventions were compared in these trials (sclerotherapy, beta-blockers, variceal band ligation, beta-blockers plus sclerotherapy, no active intervention, TIPS (transjugular intrahepatic portosystemic shunt), beta-blockers plus nitrates, portocaval shunt, sclerotherapy plus variceal band ligation, beta-blockers plus nitrates plus variceal band ligation, beta-blockers plus variceal band ligation, sclerotherapy plus nitrates). Overall, 22.5% of the trial participants who received the reference treatment (chosen because this was the commonest treatment compared in the trials) of sclerotherapy died during the follow-up period ranging from two months to 61 months. There was considerable uncertainty in the effects of interventions on mortality. Accordingly, none of the interventions showed superiority over another. None of the trials reported health-related quality of life. Based on low-certainty evidence, variceal band ligation may result in fewer serious adverse events (number of people) than sclerotherapy (OR 0.19; 95% CrI 0.06 to 0.54; 1 trial; 100 participants). Based on low or very low-certainty evidence, the adverse events (number of participants) and adverse events (number of events) may be different across many comparisons; however, these differences are due to very small trials at high risk of bias showing large differences in some comparisons leading to many differences despite absence of direct evidence. Based on low-certainty evidence, TIPS may result in large decrease in symptomatic rebleed than variceal band ligation (HR 0.12; 95% CrI 0.03 to 0.41; 1 trial; 58 participants). Based on moderate-certainty evidence, any variceal rebleed was probably lower in sclerotherapy than in no active intervention (HR 0.62; 95% CrI 0.35 to 0.99, direct comparison HR 0.66; 95% CrI 0.11 to 3.13; 3 trials; 296 participants), beta-blockers plus sclerotherapy than sclerotherapy alone (HR 0.60; 95% CrI 0.37 to 0.95; direct comparison HR 0.50; 95% CrI 0.07 to 2.96; 4 trials; 231 participants); TIPS than sclerotherapy (HR 0.18; 95% CrI 0.08 to 0.38; direct comparison HR 0.22; 95% CrI 0.01 to 7.51; 2 trials; 109 participants), and in portocaval shunt than sclerotherapy (HR 0.21; 95% CrI 0.05 to 0.77; no direct comparison) groups. Based on low-certainty evidence, beta-blockers alone and TIPS might result in more, other compensation, events than sclerotherapy (rate ratio 2.37; 95% CrI 1.35 to 4.67; 1 trial; 65 participants and rate ratio 2.30; 95% CrI 1.20 to 4.65; 2 trials; 109 participants; low-certainty evidence). The evidence indicates considerable uncertainty about the effect of the interventions including those related to beta-blockers plus variceal band ligation in the remaining comparisons. AUTHORS' CONCLUSIONS The evidence indicates considerable uncertainty about the effect of the interventions on mortality. Variceal band ligation might result in fewer serious adverse events than sclerotherapy. TIPS might result in a large decrease in symptomatic rebleed than variceal band ligation. Sclerotherapy probably results in fewer 'any' variceal rebleeding than no active intervention. Beta-blockers plus sclerotherapy and TIPS probably result in fewer 'any' variceal rebleeding than sclerotherapy. Beta-blockers alone and TIPS might result in more other compensation events than sclerotherapy. The evidence indicates considerable uncertainty about the effect of the interventions in the remaining comparisons. Accordingly, high-quality randomised comparative clinical trials are needed.
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Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials.
Gaudry, S, Hajage, D, Benichou, N, Chaïbi, K, Barbar, S, Zarbock, A, Lumlertgul, N, Wald, R, Bagshaw, SM, Srisawat, N, et al
Lancet (London, England). 2020;(10235):1506-1515
Abstract
BACKGROUND The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury. METHODS In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025). FINDINGS Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI -0·04 to 0·06). There was no heterogeneity across studies (I2=0%; τ2=0), and most studies had a low risk of bias. INTERPRETATION The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. FUNDING None.
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Efficacy and safety of direct oral anticoagulants for secondary prevention of cancer associated thrombosis: a meta-analysis of randomized controlled trials.
Desai, R, Koipallil, GK, Thomas, N, Mhaskar, R, Visweshwar, N, Laber, D, Patel, A, Jaglal, M
Scientific reports. 2020;(1):18945
Abstract
Direct oral anticoagulants (DOACs) may be good alternatives to low molecular weight heparin (LMWH) or vitamin K antagonists (VKA) for treatment of cancer associated thrombosis (CAT). We conducted a meta-analysis of ten randomized clinical trials to evaluate the efficacy and safety of DOACs in patients with CAT. All had study populations composed in entirety or in part of patients with CAT. The primary outcome (efficacy) was recurrent VTE and the secondary outcomes (safety outcomes) included major bleeding, clinically relevant non-major bleeding (CRNMB), and all bleeding (major bleeding + CRNMB). Participants treated with DOACs had lower risk of recurrent VTE, overall (RR 0.63; 95% CI 0.51-0.79; p < 0.0001), compared to LMWH (RR 0.57; 95% CI 0.40-0.83; p = 0.003), but not compared to VKA (RR 0.69; 95% CI 0.44-1.06; p = 0.09). Compared to LMWH, DOACs showed no difference in major bleeding risk (RR 1.31; 95% CI 0.78-2.18; p = 0.31), though had higher risk of CRNMB (RR 1.60; 95% CI 1.13-2.26; p = 0.008) and all bleeding (RR 1.49; 95% CI 1.10-2.01; p = 0.010). These results indicate that DOACs are more effective than LMWH for prevention of recurrent VTE with CAT though carry an increased risk for non-major bleeding compared to standard of care, LMWH.
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Effect and efficacy of lifestyle interventions as secondary prevention.
Liljehult, J, Christensen, T, Molsted, S, Overgaard, D, Mesot Liljehult, M, Møller, T
Acta neurologica Scandinavica. 2020;(4):299-313
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INTRODUCTION Improvements in health behaviour are often recommended as part of secondary prevention in patients with stroke and transient ischaemic attack. However, there is a lack of knowledge as to how this is applied in clinical practice. AIM: In this systematic review and meta-analysis, we examined the effect of counselling or educational intervention directed at individual or multiple behavioural risk factors on blood pressure and other reported outcomes. METHODS PubMed, Embase, PsycInfo, CINAHL, Scopus and Web of Science were systematically searched. Meta-analyses were conducted on all outcome measures if appropriate. A qualitative analysis of the content of the interventions was conducted to review which elements the interventions consisted of. RESULTS Twenty-nine randomized controlled trials were identified. Fourteen reported effects on systolic blood pressure, and pooled results showed a significant beneficial effect (n = 2,222; -3.85 mmHg [95%CI -6.43; -1.28]). The effect was greatest in the four interventions which included supervised training (n = 174; -9.83 mmHg [95%CI -16.56; -3.09]). CONCLUSION Modifying health behaviour in stroke survivors might have a moderate beneficial effect on blood pressure, especially if the intervention includes supervised physical training.
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Omega-3, omega-6, and total dietary polyunsaturated fat for prevention and treatment of type 2 diabetes mellitus: systematic review and meta-analysis of randomised controlled trials.
Brown, TJ, Brainard, J, Song, F, Wang, X, Abdelhamid, A, Hooper, L, ,
BMJ (Clinical research ed.). 2019;:l4697
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OBJECTIVE To assess effects of increasing omega-3, omega-6, and total polyunsaturated fatty acids (PUFA) on diabetes diagnosis and glucose metabolism. DESIGN Systematic review and meta-analyses. DATA SOURCES Medline, Embase, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform, Clinicaltrials.gov, and trials in relevant systematic reviews. ELIGIBILITY CRITERIA Randomised controlled trials of at least 24 weeks' duration assessing effects of increasing α-linolenic acid, long chain omega-3, omega-6, or total PUFA, which collected data on diabetes diagnoses, fasting glucose or insulin, glycated haemoglobin (HbA1c), and/or homoeostatic model assessment for insulin resistance (HOMA-IR). DATA SYNTHESIS Statistical analysis included random effects meta-analyses using relative risk and mean difference, and sensitivity analyses. Funnel plots were examined and subgrouping assessed effects of intervention type, replacement, baseline risk of diabetes and use of antidiabetes drugs, trial duration, and dose. Risk of bias was assessed with the Cochrane tool and quality of evidence with GRADE. RESULTS 83 randomised controlled trials (mainly assessing effects of supplementary long chain omega-3) were included; 10 were at low summary risk of bias. Long chain omega-3 had little or no effect on likelihood of diagnosis of diabetes (relative risk 1.00, 95% confidence interval 0.85 to 1.17; 58 643 participants, 3.7% developed diabetes) or measures of glucose metabolism (HbA1c mean difference -0.02%, 95% confidence interval -0.07% to 0.04%; plasma glucose 0.04, 0.02 to 0.07, mmol/L; fasting insulin 1.02, -4.34 to 6.37, pmol/L; HOMA-IR 0.06, -0.21 to 0.33). A suggestion of negative outcomes was observed when dose of supplemental long chain omega-3 was above 4.4 g/d. Effects of α-linolenic acid, omega-6, and total PUFA on diagnosis of diabetes were unclear (as the evidence was of very low quality), but little or no effect on measures of glucose metabolism was seen, except that increasing α-linolenic acid may increase fasting insulin (by about 7%). No evidence was found that the omega-3/omega-6 ratio is important for diabetes or glucose metabolism. CONCLUSIONS This is the most extensive systematic review of trials to date to assess effects of polyunsaturated fats on newly diagnosed diabetes and glucose metabolism, including previously unpublished data following contact with authors. Evidence suggests that increasing omega-3, omega-6, or total PUFA has little or no effect on prevention and treatment of type 2 diabetes mellitus. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42017064110.
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Effect of statins and non-statin LDL-lowering medications on cardiovascular outcomes in secondary prevention: a meta-analysis of randomized trials.
Koskinas, KC, Siontis, GCM, Piccolo, R, Mavridis, D, Räber, L, Mach, F, Windecker, S
European heart journal. 2018;(14):1172-1180
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AIMS: Current evidence on dyslipidaemia management has expanded to novel treatments and very low achieved levels of low-density lipoprotein cholesterol (LDL-C). We sought to compare the clinical impact of more-intensive vs. less-intensive LDL-C lowering by means of statins and currently recommended non-statin medications in secondary prevention. METHODS AND RESULTS We searched Medline, EMBASE, and Cochrane databases for randomized controlled trials of statins, ezetimibe, proprotein convertase subtilisin-kexin type 9 (PCSK9) inhibitors, or bile acid sequestrants with >500 patients followed for ≥1 year. We employed random-effects models using risk ratios (RRs) with 95% confidence intervals (CIs) to compare outcomes. We included 19 trials (15 of statins, 3 of PCSK9 inhibitors, and 1 of ezetimibe) with 152 507 patients randomly assigned to more-intensive (n = 76 678) or less-intensive treatment (n = 75 829). More-intensive treatment was associated with 19% relative risk reduction for the primary outcome, major vascular events (MVEs; RR 0.81, 95% CI 0.77-0.86). Risk reduction was greater across higher baseline levels and greater achieved reductions of LDL-C. The clinical benefit was significant across varying types of more-intensive treatment and was consistent for statins (RR 0.81, 95% CI 0.76-0.86) and non-statin agents (PCSK9 inhibitors and ezetimibe; RR 0.85, 95% CI 0.77-0.94) as active (more-intensive) intervention (P-interaction = 0.38). Each 1.0 mmol/L reduction in LDL-C was associated with 19% relative decrease in MVE. Death, cardiovascular death, myocardial infarction, stroke, and coronary revascularization also favoured more-intensive treatment. CONCLUSION Reduction of MVE is proportional to the magnitude of LDL-C lowering across a broad spectrum of on-treatment levels in secondary prevention. Statin intensification and add-on treatment with PCSK9 inhibitors or ezetimibe are associated with significant reduction of cardiovascular morbidity in this very high-risk population.
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Interventions for improving modifiable risk factor control in the secondary prevention of stroke.
Bridgwood, B, Lager, KE, Mistri, AK, Khunti, K, Wilson, AD, Modi, P
The Cochrane database of systematic reviews. 2018;(5):CD009103
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BACKGROUND People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review. OBJECTIVES To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention. DATA COLLECTION AND ANALYSIS Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables. MAIN RESULTS The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes. AUTHORS' CONCLUSIONS We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.
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Effectiveness of interventions involving nurses in secondary stroke prevention: A systematic review and meta-analysis.
Parappilly, BP, Field, TS, Mortenson, WB, Sakakibara, BM, Eng, JJ
European journal of cardiovascular nursing. 2018;(8):728-736
Abstract
BACKGROUND AND PURPOSE Among members of the health care team, nurses play a large role in actively engaging stroke survivors in secondary stroke prevention programs. This systematic review and meta-analysis examines the effectiveness of interventions in which nurses have a primary role on modification of risk factors among stroke survivors. METHODS We systematically searched for randomized controlled trials in relevant databases investigating the role of nurses in secondary stroke prevention. Meta-analyses were conducted using Cochrane Review Manager Software. The mean pooled effect size, a 95% confidence interval (CI), and I-squared ( I2) for heterogeneity were calculated. RESULTS Sixteen randomized controlled trials were included with a total of 3568 stroke and transient ischemic attack patients. After removing one outlier, the models demonstrated a statistically significant effect on reducing systolic blood pressure (SMD = -0.14 (95% CI = -0.23, -0.05), I2 = 0%; p = 0.002, six studies, n =1885) and diastolic blood pressure (SMD = -0.16 (95% CI = -0.27, -0.05), I2 = 0%; p = 0.003, four studies, n =1316). The interventions also significantly improved physical activity (five studies, n=1234), diet (three studies, n=425), medication adherence (two studies, n=270), and knowledge of risk factors (three studies, n=516). However, there was no effect on smoking cessation or reduction in use of alcohol. CONCLUSION We found that interventions in which nurses had a primary role were effective on improving medical and behavioral risk factors, as well as knowledge of risk factors as part of secondary prevention of stroke.
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Blood pressure-lowering drugs and secondary prevention of cardiovascular disease: systematic review and meta-analysis.
Xie, W, Zheng, F, Evangelou, E, Liu, O, Yang, Z, Chan, Q, Elliott, P, Wu, Y
Journal of hypertension. 2018;(6):1256-1265
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OBJECTIVE To systematically evaluate the efficacy of five commonly used blood pressure-lowering drugs in reducing cardiovascular events among patients with nonacute cardiovascular disease, but without heart failure. METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials on 18 March 2017. The primary outcome was fatal and nonfatal cardiovascular events, and the secondary outcomes were all-cause death, fatal and nonfatal myocardial infarction, and stroke. Pooled risk ratios and corresponding 95% confidence intervals (CIs) were calculated using Mantel-Haenszel random-effects meta-analyses. RESULTS Twenty-seven randomized controlled trials with 143 095 participants and a treatment duration of at least 12 months were included in our analyses. Fifteen trials enrolled patients with coronary artery disease, eight enrolled patients with cerebral artery disease, and four enrolled patients with cardiovascular disease. Of the 27 trials, 10 trials only included hypertensive patients. Compared with placebo, angiotensin-converting enzyme inhibitors (ACEIs) (risk ratio 0.85, 95% CI 0.78-0.92), angiotensin receptor blockers (risk ratio 0.92, 95% CI 0.87-0.98), and diuretics (risk ratio 0.77, 95% CI 0.66-0.90) significantly reduced the risk of cardiovascular events. Apart from this, ACEIs significantly reduced all secondary outcomes, calcium channel blockers, and diuretics reduced stroke significantly. No significant difference was found in head-to-head comparisons of each given drug class with any other class. CONCLUSIONS Although only ACEIs have evidences showing its effect in reducing cardiovascular events and all secondary outcomes, head-to-head comparisons did not provide strong evidence in difference in the effects between these blood pressure-lowering drugs.
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Effect of Mobile Health Interventions on the Secondary Prevention of Cardiovascular Disease: Systematic Review and Meta-analysis.
Gandhi, S, Chen, S, Hong, L, Sun, K, Gong, E, Li, C, Yan, LL, Schwalm, JD
The Canadian journal of cardiology. 2017;(2):219-231
Abstract
BACKGROUND Despite the strong uptake of mobile health (mhealth) technology targeted at cardiovascular care, it is still unclear if this improves adherence to therapy and patient-related outcomes in those with established cardiovascular disease. METHODS A systematic search of English and Chinese language studies was conducted to investigate the benefit of mhealth technology for the secondary prevention of cardiovascular disease. RESULTS Twenty-seven studies with 5165 patients were included in the systematic review. Patients in the mhealth group showed increased adherence to medical therapy (odds ratio [OR], 4.51; P < 0.00001), as well as increased adherence to pharmacologic and nonpharmacologic therapy (OR, 3.86; P < 0.00001). Patients in the mhealth group showed the ability to meet recommended blood pressure targets (OR, 2.80; P < 0.001) with a trend toward the ability to meet exercise goals (OR, 2.55; P = 0.07), however, no significant difference in smoking cessation (OR, 1.42; P = 0.45) and the ability to meet lipid target levels (OR, 1.16; P = 0.29) was found. Patients in the mhealth group did not show a reduction in hospital readmission (OR, 0.93; P = 0.96), with a small number of studies showing a reduction in angina (OR, 0.23; P = 0.005), and a decrease in transient ischemic attack/stroke recurrence in those with cerebrovascular disease (OR, 0.18; P < 0.0001) and a trend toward lower observed mortality rate (OR, 0.19; P = 0.06). CONCLUSIONS The mhealth group compared with the usual care group had increased adherence to medical therapy, ability to reach blood pressure targets, exercise goals, and showed less anxiety and increased awareness of diet and exercise. There was no difference in smoking cessation, ability to meet low-density lipoprotein cholesterol targets, and hospital readmission.