Stroke prevention: exercise prescription vs. medication? A Meta-analysis published by Huseyin Naci, a researcher at the London School of Economics and Political Science, UK, and John P.A. Ioannidis, Stanford Prevention Research Center, Stanford University School of Medicine, USA, suggests that in secondary prevention of coronary heart disease, the survival benefit of exercise is essentially similar to that of pharmacological interventions, and that exercise is even more effective than pharmacological treatment in stroke patients. However, in subjects with prediabetes, there did not appear to be a clear survival benefit for either exercise or pharmacological interventions. A total of 16 Meta-analyses comparing the effects of exercise and pharmacological interventions on the risk of death were retrieved from Medline and Cochrane databases. After adding three recently published exercise-related studies, the investigators conducted a retrospective analysis of 305 randomized controlled studies that included a total of 339,274 subjects, of which a total of 14,716 subjects were randomized to exercise interventions in 57 studies. The analysis showed no statistically significant difference in survival benefit between exercise and pharmacological interventions in the secondary prevention of coronary heart disease. Among patients with coronary artery disease, statins, beta-blockers, angiotensin-converting enzyme inhibitors, and antiplatelet agents all reduced the risk of death by 18%, 15%, 17%, and 17%, respectively, compared with placebo or conventional therapy. The survival benefit of exercise intervention was essentially similar to that of drug therapy, except that the confidence interval was relatively wide (OR=0.89, 95% CI: 0.76 to 1.04). In stroke patients, exercise was more effective than drug therapy: the risk of death was 91% (OR=0.09) and 90% (OR=0.10) lower in the exercise intervention group compared with those treated with anticoagulants or antiplatelet agents, respectively. Compared with antiplatelet agents, anticoagulants appeared to be slightly less effective (OR=1.11, 95% CI: 1.00 to 1.21). The investigators noted that although the survival benefit of exercise interventions for stroke patients was greater than that of drugs, the results may be subject to substantial uncertainty given the small number of incident cases in the relevant studies. However, in the treatment of heart failure, the benefit of diuretics in reducing the risk of death was significantly greater than that of exercise interventions (OR=0.24). Treatment with diuretics or β-blockers contributed to an 81% and 29% reduction in the risk of death in patients with heart failure compared with placebo or conventional therapy, respectively. Diuretics also continued to have a survival benefit when compared with angiotensin-converting enzyme inhibitors, β-blockers, and angiotensin II receptor antagonists (ORs 0.21, 0.27, and 0.21, respectively). In a secondary analysis comparing exercise interventions with pharmacological treatment, there was no significant difference in the effect of the two treatment modalities on coronary artery disease, heart failure, and prediabetes. When all pharmacological intervention modalities were combined for sensitivity analysis, there was no difference in survival benefit between exercise and pharmacological treatment for patients with coronary heart disease (OR=0.94), prediabetes (OR=1.43) and heart failure (OR=0.99), while exercise intervention was more effective than pharmacological for stroke patients (OR=8.66). The above suggests that there was no difference between exercise and medication in terms of survival benefit in patients with coronary heart disease, prediabetes and heart failure, while exercise intervention was more effective than medication in patients with stroke.