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An updated network meta-analysis of non-pharmacological interventions for primary hypertension in adults: insights from recent studies

Systematic Reviews volume 13, Article number: 318 (2024) Cite this article

Abstract

Background

Primary hypertension significantly impacts global cardiovascular health, contributing to increased mortality rates and posing a substantial public health challenge. Recognizing the growing evidence supporting non-pharmacological interventions (NPIs) for controlling primary hypertension, our study employs Network Meta-Analysis (NMA) to comprehensively assess their efficacy.

Methods

This review updates a prior systematic review by searching for original literature on NPIs for primary hypertension from 2013 to 2024. We conducted a thorough search in eight databases, including PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, Allied and Complementary Medicine Database, CNKI, WanFang Data, and Chongqing VIP, identifying potential randomized controlled trials (RCTs) from January 1, 2013, to August 1, 2024. Primary outcomes included the mean changes in blood pressure before and after treatment. Analysis was performed using GeMTC package (R 4.2.3), and Stata 17.0. The confidence of evidence was examined using Confidence in Network Meta-Analysis (CINeMA).

Results

Utilizing NMA, we reviewed 9,189 studies, identifying 54 eligible articles with 5,827 participants. Investigating 22 distinct NPIs, the focus was on changes in systolic and diastolic blood pressure pre and post-treatment. Lifestyle intervention + Tai Chi significantly reduced systolic (-21.75 mm Hg; 95% CI -33.25 to -10.02) and diastolic blood pressure (-13.62 mm Hg; 95% CI -23.14 to -3.71) compared to usual care and other NPIs. Consistency and regression analyses did not reveal significant differences.

Conclusion

This review provides a comprehensive evaluation of NPIs for primary hypertension, emphasizing lifestyle + Tai Chi as a preferred NPI. Breathing exercises show potential in lowering systolic blood pressure, and acupuncture + tui na demonstrates effectiveness in reducing diastolic blood pressure, outperforming other interventions. The study reinforces the role of NPIs in managing primary hypertension, providing a foundation for future hypertension research.

Peer Review reports

Introduction

Primary hypertension, recognized as a major contributor to global cardiovascular diseases and mortality, has evolved into a significant public health concern [1]. The worldwide prevalence of hypertension exceeds one billion individuals [2], particularly affecting low-income economies, emphasizing the imperative need for optimizing prevention and management strategies [3]. Recent data from India underscores the substantial risks of coronary artery disease and stroke associated with hypertension, with rates reaching 17.9% and 34.6%, respectively [4]. The challenges in managing hypertension are exacerbated by the fact that more than 50% of hypertensive patients require concurrent administration of multiple antihypertensive medications to meet the recommended blood pressure targets [5]. Unfortunately, adverse effects and high costs from multi-drug therapy often reduce patient adherence, hindering blood pressure control [6]. Globally, less than 30% of hypertensive patients achieve adequate blood pressure control, and approximately 9% discontinue treatment due to adverse effects [3, 7]. These challenges have prompted the development of non-pharmacological intervention (NPI) strategies to complement pharmacological treatment and enhance therapeutic efficacy.

Recognizing the potential benefits of NPIs, the International Society of Hypertension and the American Heart Association designate them as preferred recommendations, especially for individuals with prehypertension and mild hypertension [8, 9]. However, practical implementation faces several challenges. Firstly, while multiple studies have demonstrated the antihypertensive efficacy of NPIs [10,11,12], there is still limited understanding regarding the comparative effectiveness of various NPIs, including aerobic exercise, dietary approaches to stop hypertension (DASH) diet, lifestyle modifications, etc. Additionally, the existing body of high-quality research on NPIs is limited, which contributes to their lower recommendation levels in clinical guidelines [8, 9, 13, 14]. Moreover, healthcare professionals involved in community-based chronic disease management are required by national action plans to have a medical background and receive specialized training [15]; however, there is often a shortage of such trained professionals, particularly in middle- and low-income countries [16].

Previous meta-analyses have primarily focused on evaluating the impact of individual NPIs on primary hypertension [17,18,19]. However, many of these analyses are based on studies conducted several years ago and are predominantly from western countries. As a result, interventions commonly used in regions with a high prevalence of hypertension, such as Asia, are underrepresented in clinical guidelines. To address this gap, our study includes data from major Chinese databases. Given China's large population and high prevalence of hypertension, this inclusion is crucial for a more comprehensive assessment of NPIs.

To synthesize these diverse data sources, we plan to employ network meta-analysis (NMA) methodology, integrating existing research findings through both direct and indirect comparisons. This approach will provide a more precise assessment of the differential therapeutic effects of various NPIs, further enhancing our understanding of their role in managing primary hypertension.

Methods

Protocol development and registration

This analysis followed the Preferred Reporting Items for Systematic Reviews and Network Meta-Analyses (PRISMA-NMA) checklist [20], and was registered with PROSPERO (registration number: CRD42023420357). The detailed PRISMA checklist can be found in Additional file 1.

Eligibility criteria and exclusion criteria

Type of studies

All parallel randomized controlled trials (RCTs) focusing on NPIs for primary hypertension were included, regardless of language or publication type. Exclusions comprised low-quality RCTs, animal experiments and case reports. Low-quality studies are defined as those that did not perform random allocation or had other factors that could compromise the reliability of the study (e.g., insufficient sample size or incomplete data).

Type of participants

All participants diagnosed with primary hypertension were included. Primary hypertension was defined as office systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg, or as individuals currently on antihypertensive medication with a documented history of hypertension prior to the initiation of treatment.

Type of intervention and control group

A reverse search was conducted to collect potential NPIs studied for primary hypertension in recent years, yielding interventions such as exercise, relaxation, acupuncture, low sodium diet, yoga, lifestyle, meditation, breathing exercises, tai chi, behavior, and stress reduction. Therefore, we included studies incorporating, but not limited to, these 10 therapies. The control group consisted of either other NPIs or usual care. The usual care was defined as participants maintaining their usual lifestyle without making any changes during the intervention period.

Type of outcomes

The primary outcome indicators were mean changes in SBP and DBP from baseline. Additionally, adverse reactions associated with the intervention were also collected.

Search strategy

A systematic search for eligible RCTs was conducted in eight databases from January 1, 2013, to August 1, 2024, including PubMed, Embase, Web of Science, the Cochrane Central Register of Controlled Trials (CENTRAL), Allied and Complementary Medicine Database (AMED), and three Chinese databases (CNKI, WanFang data, and Chongqing VIP). A reverse search identified a comprehensive list of NPIs studied for primary hypertension. Detailed search strategies are presented in Additional file 2. Reference lists and related reviews were checked for additional eligible studies.

Study selection and data extraction

Two independent reviewers (Ziwen Chen and Tao Xu) screened titles and abstracts of potentially eligible studies, followed by full-text reviews to determine studies meeting inclusion criteria. A team of three reviewers (Qifu Li, Xueli Zhou, and Yunjie Shu) conducted data extraction, collecting information on study characteristics, participant demographics (age, gender, country, number of participants, BMI and medication status), intervention details, baseline blood pressure values, and post-intervention changes in SBP and DBP. Discrepancies were resolved through internal discussions.

Assessment of bias and overall study quality

The risk of bias in each study was assessed using the Cochrane Risk of Bias 2.0 Tool. Two reviewers (Qifu Li and Xueli Zhou) provided assessments and reasons for each evaluation. Discrepancies were resolved through internal discussions, and if necessary, consultation with another reviewer (Fanrong Liang). In addition, we examined the confidence of evidence using the Confidence of Network Meta-Analysis (CINeMA) web application, which grades the confidence of the results as high, moderate, low, and very low [21].

End points and handing with missing data

Changes of mean difference (MD) and standard deviation (SD) of SBP and DBP from baseline were assessed as effect sizes. When studies reported standard errors or 95% confidence intervals (CI), they were converted to SD using sample size (n). In cases where changes from baseline were not reported but baseline and post-treatment blood pressure values were provided, MD and SD were calculated using the formula recommended in the Cochrane Handbook [22].

Statistical analysis

Traditional meta-analysis utilized a random-effects model for each direct comparison. Subsequently, a Bayesian NMA was performed using the GeMTC package (R 4.2.3). Markov Chain Monte Carlo simulation with four chains, running for 50,000 iterations and annealed after 20,000 iterations, was used for random-effects model analysis. Network consistency was assessed using the Deviance Information Criterion (DIC), and node-splitting method examined the Bayesian P-value between direct and indirect evidence. Overall heterogeneity in the analysis was examined using the I2 statistic (I2 greater than 75% indicates high heterogeneity; less than 25% indicates low heterogeneity).

To assess the effectiveness of each treatment, ranking probabilities were calculated based on their likelihood of being the best option among all treatments. Publication bias was evaluated using comparison-adjusted funnel plots and the netfunnel command in Stata 17.0. To further refine our analysis, we conducted additional meta-regression analyses that considered several key variables: antihypertensive medication use, the method of blood pressure measurement (24-h ambulatory monitoring vs. office measurements), and the duration of non-pharmacological interventions (categorized as 0–12 weeks, 12–24 weeks, and more than 24 weeks).

Results

Literature search results

A total of 9,189 references were initially retrieved in the search. After removing duplicates, 6,958 studies underwent further detailed analysis. Of these, 5,749 were excluded following the preliminary screening of titles or abstracts, and an additional 1,155 were excluded after a thorough review of the full-text articles. Ultimately, 54 studies were retained, encompassing 21 distinct interventions and involving a total of 5,827 patients [10, 11, 23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64]. The study flowchart is presented in Fig. 1, and detailed baseline characteristic data are available in Table 1.

Fig. 1
figure 1

PRISMA flow diagram of study selection process

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Table 1 Main characteristics of included trials
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Study characteristics

In summary, a total of 3,020 participants were allocated to the intervention group, while 2,807 participants were assigned to the control group across the included studies. These studies recruited participants from Asia (61.11%), the Americas (25.93%), Europe (11.11%), and Africa (1.85%). Among these participants, 46.30% did not use antihypertensive medications during the trial, while 53.70% were on such medications. Regarding blood pressure measurement methods, 72.22% of the RCTs used office-based measurements, whereas 27.78% employed ambulatory blood pressure monitoring (ABPM). The trials also varied in duration: 21 studies (38.89%) had an intervention period of up to 12 weeks, another 21 studies (38.89%) lasted between 12 and 24 weeks, and 12 studies (22.22%) extended beyond 24 weeks. Additionally, there were five three-arm trials, which were analyzed as five independent two-arm trials, with sample sizes evenly distributed.

Network meta-analysis

In traditional pair-wise meta-analyses, it was found that 13 interventions were more effective at reducing SBP, and 10 interventions were more effective at lowering DBP compared to usual care. Results can be found in Table 2 (A, B).

Table 2 Results of pair-wise meta-analysis
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The NMA involved 54 RCTs, including 5,827 participants, and encompassed 21 interventions along with usual care. Out of these, 16 NPIs were directly compared to usual care, and 11 interventions were directly compared to at least one other intervention (Fig. 2). Comparative effect estimates for 22 NPIs in terms of blood pressure reduction can be found in Fig. 3 (A, B). Given that indirect comparisons provided observational evidence in this NMA, we placed our focus on interventions with demonstrated efficacy in lowering blood pressure, as supported by the combined evidence from both direct and indirect comparisons.

Fig. 2
figure 2

Network plot of NPIs for primary hypertension. The size of the nodes represents the sample size. The thickness of the lines represents the number of studies included in the comparison

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Fig. 3
figure 3

Forest plots for the mean change of primary hypertension. A Forest plot for the mean change of SBP; (B) Forest plot for the mean change of DBP

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In terms of reducing SBP, 14 interventions were found to be more effective than usual care (Fig. 3A). According to the results of surface under the cumulative ranking (SUCRA) probabilities, the top ten ranking intervention measures were as follows: lifestyle + tai chi (−21.75 mm Hg [95% CI, −33.25 to −10.02]), lifestyle + tui na (−19.14 mm Hg [95% CI, −30.66 to −7.48]), breathing exercise (−17.00 mm Hg [95% CI, −26.28 to −7.72]), acupuncture + music (−16.62 mm Hg [95% CI, −23.71 to −9.56]), acupuncture + tui na (−16.00 mm Hg [95% CI, −27.01 to −6.05]), music + stress reduction (−15.20 mm Hg [95% CI, −25.22 to −5.16]), aerobic exercise + low sodium diet (−14.61 mm Hg [95% CI, −24.09 to −5.11]), DASH + aerobic exercise (−11.35 mm Hg [95% CI, −18.96 to −3.75]), tai chi (−9.73 mm Hg [95% CI, −14.2 to −5.35]), and acupuncture (−9.53 mm Hg [95% CI, −12.64 to −6.48]). And the other interventions included lifestyle, music, yoga, and low sodium diet (Fig. 3A and Fig. 4A).

Fig. 4
figure 4

SUCRA probabilities plots of blood pressure reduction. A SUCRA probabilities plot of SBP; (B) SUCRA probabilities plot of DBP

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In the context of DBP reduction, SUCRA rankings indicated that the following interventions outperformed usual care: lifestyle + tai chi (−13.62 mm Hg [95% CI, −23.14 to −3.71]), acupuncture + tui na (−12.93 mm Hg [95% CI, −21.27 to −4.74]), acupuncture + music (−8.33 mm Hg [95% CI, −14.02 to −2.6]), music (−7.11 mm Hg [95% CI, −12.37 to −1.84]), acupuncture (−6.75 mm Hg [95% CI, −9.23 to −4.2]), tai chi (−6.7 mm Hg [95% CI, −10.14 to −3.33). These findings are depicted in Fig. 3B and Fig. 4B.

Risk of bias

In assessing the quality of the studies, we followed the guidelines provided by the Cochrane Handbook. Of 54 eligible RCTs, 3 were deemed at low risk of bias across all domains, 50 were considered to have some bias and 1 had at least one domain with high risk of bias (Additional file 3).

Inconsistency and heterogeneity

Detailed results of node-splitting and heterogeneity tests can be found in Additional file 4. Notably, no inconsistencies were identified in SBP or DBP, as supported by the model parameters. The consistency and inconsistency tests for SBP resulted in DIC values of 207.02 and 210.24, respectively, while for DBP, they were 208.54 and 211.64, respectively. Additionally, the results of the node-splitting analysis revealed the absence of local incoherence in both models. Every Bayesian P-value was greater than 0.05, indicating the overall coherence and consistency of the data.

However, heterogeneity was observed in some studies. To investigate this, meta-regression was performed using the GeMTC package in R, involving network construction and iterative regression modeling. The analysis evaluated the impact of variables including blood pressure measurement methods (24-h ambulatory monitoring vs. office measurements), antihypertensive medication status (use vs. non-use), and intervention duration (< 12 weeks, 12–24 weeks, > 24 weeks). For SBP, the coefficients with different variables were: measurement method, 1.41 (95% CI: [−2.85, 5.50]); medication status, −2.80 (95% CI: [−41.01, 6.00]); intervention duration, 2.63 (95% CI: [−1.75, 6.86]). For DBP, the coefficients were: measurement method, 1.06 (95% CI: [−2.51, 4.64]); medication status, −0.66 (95% CI: [−3.56, 2.25]); intervention duration, 2.54 (95% CI: [−0.73, 5.67]). None of these variables had a statistically significant impact on the overall outcomes (P > 0.05). This suggests that observed heterogeneity may be due to differences in baseline characteristics, as well as variations in interventions. The lack of standardized NPI strategies in current guidelines also contributes to unavoidable heterogeneity.

Publication bias and certainty of the evidence

To assess reporting bias, the symmetry of the adjusted funnel plots was compared. Based on the funnel plots for SBP (Fig. 5A) and DBP (Fig. 5B), most of the included studies are symmetrically distributed on both sides of the central line, which suggest a reduced likelihood of small sample effects and publication bias. The certainty of the evidence in this NMA, as assessed by CINeMA, ranged from very low to moderate across most comparisons. This reflects limitations due to some concerns in study quality and precision (Additional file 5).

Fig. 5
figure 5

Funnel plots for the analysis of primary hypertension. A Funnel plot for the analysis of SBP; (B) Funnel plot for the analysis of DBP. A: acupuncture + tui na; B: aerobic exercise + low sodium diet; C: low sodium diet; D: DASH; E: DASH + aerobic exercise; F: acupuncture; G: acupuncture + music; H: aerobic exercise; I: aerobic exercise + yoga; J: lifestyle; K: lifestyle + tai chi; L: lifestyle + tui na; M: music; N: music + breathing exercise; O: music + stress reduction; P: stress reduction; Q: tai chi; R: tui na; S: yoga; T: yoga + lifestyle; U: usual care; V: breathing exercise

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Discussion

To our knowledge, this study represents the first attempt to provide an updated assessment of the effectiveness of NPIs in treating primary hypertension. The primary goal is to evaluate and discuss the efficacy of these interventions in managing high blood pressure. While emphasizing the significance of lifestyle modifications for hypertensive patients, it also highlights increased attention to therapies widely utilized in developing countries, such as tai chi and acupuncture [14]. Among the top-ranking strategies, lifestyle + tai chi, lifestyle + tui na, and breathing exercise emerge as effective methods for reducing SBP, while lifestyle + tai chi, acupuncture + tui na, and acupuncture + music show promise in reducing DBP.

This study underlines the importance of comprehensive lifestyle modifications, aligning with the 2017 ACC/AHA guidelines advocating for lifestyle interventions in individuals with elevated or high blood pressure [14]. Additionally, research also suggests that lifestyle interventions are effective for individuals with resistant hypertension [12]. The improving lifestyle not only helps prevent traditional risk factors for hypertension, such as obesity and insulin resistance, but also enhances vascular health through reductions in oxidative stress and inflammation [65]. It reduces sympathetic nervous system overactivity and impacts non-traditional mechanisms, such as increased myokine secretion, thereby contributing to blood pressure reduction [65, 66]. Furthermore, tai chi is considered highly effective for reducing blood pressure. Tai chi combines elements of increased body awareness, balance training, meditation, and gentle movements with pleasurable characteristics [67]. Researches indicate that tai chi can improve joint health, modulate the pressure sensors in the aortic arch and carotid sinus, leading to reduced blood pressure and coronary artery dilation [68, 69]. In summary, our study underscores the effectiveness of lifestyle + tai chi in managing hypertension. Notably, based on its highest SUCRA rankings, lifestyle + tai chi demonstrates significant effects in reducing both SBP and DBP, and it recommended as a preferred NPI for individuals with primary hypertension.

According to SUCRA rankings, breathing exercise shows relatively better performance in reducing SBP. Studies suggest that short episodes of deep breathing (6 times/30 s) can lead to a reduction of 3.4 to 3.9 mm Hg in SBP within a few minutes when compared to resting quietly [70]. There are also indications that the use of deep breathing techniques may result in a persistent blood pressure reduction over several weeks to months [71, 72]. This effect may be associated with the activity of the sympathetic nervous system, which is typically elevated due to the malfunction of arterial and cardiopulmonary pressure receptors, leading to sustained elevated blood pressure [73]. Slow breathing, at a rate of fewer than 10 times per minute, especially with prolonged expiration, appears to reduce the activation of the sympathetic nervous system and induce dilation of small arteries [74]. This process may be triggered by the activation of pulmonary stretch receptors, which respond to the increased tidal volume of slow breathing [72, 75]. This mechanism may also interact with cardiac baroreceptors to inhibit the release of the sympathetic nervous system [76]. Therefore, the mechanism of action in slowing the breathing rate may contribute to increasing pressure receptor sensitivity. Moreover, the American Heart Association classifies device-guided breathing as a Class IIA evidence B recommendation [13], suggesting that using device-guided breathing for blood pressure reduction is reasonable in clinical practice.

When focusing on DBP reduction, the SUCRA results favored the efficacy of acupuncture + tui na. Acupuncture and tui na are both integral components of traditional Chinese medicine and are extensively utilized in Asian regions. A single-blind RCT conducted in Germany found that patients who received 6 weeks of acupuncture treatment experienced a significant decrease in 24-h ambulatory blood pressure compared to a sham acupuncture group, with reductions of 6.4 mm Hg (95% CI, 3.5–9.2) and 3.7 mm Hg (95% CI, 1.6–5.8) for SBP and DBP, respectively [77]. Another double-blind RCT conducted in Korea found that acupuncture, as an adjunct therapy to antihypertensive medication or lifestyle modification, led to a reduction in blood pressure from 136.8/83.7 to 122.1/76.8 mm Hg compared to sham acupuncture [78]. Additionally, related meta-analyses have indicated that the efficacy of tui na combined with antihypertensive medication is significantly better than using antihypertensive medication alone [79, 80]. Although there are fewer studies directly comparing these two approaches, our analysis suggests that the combined antihypertensive effect of acupuncture + tui na is better, especially in reducing DBP with a significant advantage of −12.93 (95% CI, −21.27 to −4.74).

Although no statistically significant differences were found in blood pressure measurements, it's important to note that only a limited number of studies used ABPM despite its greater reliability in reflecting true blood pressure compared to casual or office measurements. ABPM is also effective in detecting conditions such as white coat syndrome, masked hypertension, or nocturnal hypertension, which standard measurements may miss [81, 82]. Therefore, we recommend that future research incorporate ABPM to enhance the precision of blood pressure assessments.

Currently, studies of NPIs for primary hypertension typically focus on specific individual interventions and lack comprehensive comparisons of different NPIs. Our study fills this knowledge gap by directly and indirectly comparing multiple NPIs that have been widely used over the past decade. This is not only valuable for refining existing evidence within the field but also holds significant relevance for countries with a high prevalence of hypertensive patients and limited healthcare resources.

The implementation of NPIs may offer a promising approach to alleviate the disease burden among individuals with stage 1 and early-stage hypertension. Additionally, it emerges as a preferable strategy for achieving comprehensive blood pressure control, especially in patients with treatment-resistant hypertension. As a result, we recommend that governmental authorities launch training programs aimed at preparing a larger workforce of community-based chronic disease managers who are well-equipped to effectively execute these interventions. For policymakers, a thorough analysis discerning the most effective interventions would furnish valuable evidence to inform optimal health-related decisions. Our study underscores that the combination of lifestyle + tai chi demonstrates superior efficacy in reducing blood pressure when compared to other NPIs. Consequently, governmental departments and community-based chronic disease managers may consider prioritizing the reinforcement of this particular intervention. Although, it is imperative to acknowledge that the long-term effects of these antihypertensive interventions, including their potential to reduce the incidence of cardiovascular events, necessitate further substantiation through additional studies to provide more comprehensive evidence.

Nevertheless, it is important to note several limitations in this study. Firstly, our focus is predominantly on evaluating the effectiveness of NPIs in reducing blood pressure, and do not encompass secondary endpoints such as blood pressure control rates and cardiovascular events. As a result, definitive conclusions regarding the long-term real-world applications of NPIs remain elusive. Additionally, we must acknowledge the omission of smoking cessation as a variable in our study due to limited available data from RCTs, highlighting the need for further investigation in this specific area. Furthermore, our study is constrained by the absence of long-term follow-up data. While demonstrating the efficacy of NPIs for hypertensive patients, uncertainties still persist concerning long-term treatment compliance and cost-effectiveness. Therefore, it is imperative for future studies to prioritize the provision of high-quality empirical research aimed at evaluating the cost-effectiveness and feasibility of implementing NPIs.

Conclusions

In summary, this study provides a comprehensive assessment of NPIs for primary hypertension. Emphasizing the importance of lifestyle modifications aligned with ACC/AHA guidelines, the research highlights lifestyle + tai chi as a preferred NPI. Breathing exercises show promise in reducing SBP, while acupuncture + tui na proves effective in lowering DBP, surpassing other interventions. The significance of this study lies in providing further evidence for NPIs in treating primary hypertension. It calls for future research to address secondary endpoints and long-term follow-up results to offer a comprehensive understanding.

Data availability

The datasets during and/or analyzed during the current study available from the corresponding author on reasonable request.

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Acknowledgements

We thank all the workers for their valuable time and effort in this study.

Funding

This research was funded by National Natural Science Foundation of China, grant number 82060900; the “Liang Fanrong Expert Workstation” of Yunnan Province—Yunnan Provincial Science and Technology Plan Project, grant number 202305AF150072; the Youth Special of Yunnan Province Ten-thousand Plan, grant number YNWR-QNBJ-2019–257, National Natural Science Foundation of China Regional Innovation and Development Joint Fund, grant number U21A20404 and Yunnan province innovation team of prevention and treatment for brain diseases with acupuncture and Tuina, grant number 202405AS350007.

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  1. Ziwen Chen and Qifu Li contributed equally to this work and shared the first authorship.

Authors and Affiliations

  1. Department of Acupuncture and Moxibustion, Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China

    Ziwen Chen, Qifu Li, Tao Xu, Xueli Zhou, Yunjie Shu & Fanrong Liang

  2. School of Second Clinical Medicine, The Second Affiliated Hospital, Yunnan University of Chinese Medicine, Kunming, 650500, China

    Taipin Guo

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Conceptualization, Ziwen Chen and Fanrong Liang; methodology, Fanrong Liang and Taipin Guo; software, Ziwen Chen; resources, Qifu Li, Tao Xu, Xueli Zhou and Yunjie Shu; writing—original draft preparation, Ziwen Chen; writing—review and editing, Fanrong Liang, and Taipin Guo. All authors have read and agreed to the published version of the manuscript.

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Chen, Z., Li, Q., Xu, T. et al. An updated network meta-analysis of non-pharmacological interventions for primary hypertension in adults: insights from recent studies. Syst Rev 13, 318 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13643-024-02744-5

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Systematic Reviews

ISSN: 2046-4053