Behavioral Versus Pharmacologic Strategies in Cardiovascular Prevention: A Systematic Review and Meta-analysis

Background: Cardiovascular diseases remain the leading cause of death globally. Modifiable lifestyle factors such as diet, physical activity, and smoking play a critical role in disease development. However, the comparative effectiveness of lifestyle interventions versus pharmacologic therapy for cardiovascular prevention has not been clearly quantified. Purpose: This systematic review and meta-analysis compared the effects of lifestyle modification and pharmacologic therapy on major adverse cardiovascular events, all‐cause mortality, cardiovascular mortality, and stroke incidence in middle‐aged and older adults. Methods: We searched PubMed, Embase, and Cochrane CENTRAL from inception to June 2025. We included 21 randomized controlled trials and 11 prospective cohort studies, totaling 312 645 participants. Pooled risk ratios were calculated using random‐effects models. Results: Lifestyle interventions significantly reduced major adverse cardiovascular events (risk ratio: 0.85), all‐cause mortality (0.88), cardiovascular mortality (0.84), and stroke (0.82). Combined diet and exercise programs showed the greatest benefit (risk ratio: 0.80). Results were consistent across sensitivity analyses and showed no publication bias. Conclusions: Lifestyle modification provides cardiovascular protection comparable to or greater than pharmacologic therapy. Combined behavioral programs yield the strongest effects. Clinical Implications: Healthcare systems should integrate structured lifestyle programs as a first‐line prevention strategy. Pharmacologic therapy remains valuable but should be viewed as complementary to behavioral interventions. Clinicians should prioritize diet and exercise counseling in routine practice.