Supplementary Material for: Comparative effects of non-pharmacological interventions for stroke prevention in adults: A network meta-analysis

Introduction: Existing guidelines lack comprehensive recommendations for stroke prevention. This network meta-analysis aimed to evaluate the comparative efficacy of non-pharmacological interventions in preventing total stroke and fatal stroke in high-risk adults. Methods: We pooled only randomized controlled trials (RCTs). Relative risks (RRs), 95% confidence intervals (CIs), and P-scores were computed to compare and rank the efficacy of interventions in preventing stroke. Results: 50 RCTs with 673624 participants were pooled in this study. Compared with the control group, Exercise + Education may decrease stroke risk (RR=0.23; 95% CI: 0.07 – 0.73; low strength of evidence (SOE)), followed by Exercise (RR=0.40; 95% CI: 0.28 – 0.57; moderate SOE), Mediterranean diet (RR=0.70; 95% CI: 0.50 – 0.97; low SOE), and Vitamin B6 combined with B12 and folic acid (Vitamin B6 + B12 + folic acid) (RR=0.86; 95% CI: 0.77 – 0.95; moderate SOE). Only Salt substitute showed significantly reduced fatal stroke risk (RR = 0.78; 95% CI: 0.68 - 0.90; high SOE). Exercise + Education (low SOE) and Exercise alone (moderate SOE) showed short-term benefits, while Salt substitute had long-term effects on reducing stroke risk (high SOE). Carotid endarterectomy (moderate SOE) and vitamin C (high SOE) were significantly effective in preventing ischemic stroke; and Salt substitute (high SOE) showed significantly reduced hemorrhagic stroke risk. Vitamin B6 + B12 + folic acid may lower hemorrhagic stroke, fatal hemorrhagic stroke, and transient ischemic attack risks (moderate SOE). Conclusion: Future studies should prioritize high-quality RCTs with large sample sizes, different follow-up durations and specific stroke types to confirm the efficacy of these non-pharmacological interventions.