What are the benefits and risks of exercise-based cardiac rehabilitation for heart failure?

Key messages

- Compared to no exercise, there was no evidence of a difference in deaths from any cause in patients with heart failure. Participating in exercise-based cardiac rehabilitation likely reduces the risk of hospital admissions from any cause and heart failure-related hospital admissions, and likely results in important improvements in health-related quality of life assessed by the 'Minnesota Living with Heart Failure' questionnaire.

- Importantly, this updated review provides additional evidence supporting the use of alternative modes of exercise-based cardiac rehabilitation delivery, including home-based and digitally-supported programmes.

- Future studies should recruit people not usually represented in studies, such as older patients and women with heart failure, and people with preserved ejection fraction heart failure.

What is heart failure?

Heart failure is when your heart can't pump blood around your body as well as it should. People with heart failure experience fatigue and shortness of breath. This makes doing everyday activities difficult and can affect people's quality of life. People with heart failure are at increased risk of hospital admission and death.

What is cardiac rehabilitation?

Cardiac rehabilitation aims to help people recover from heart problems, including heart failure. Cardiac rehabilitation programmes can involve exercise training and may also provide education on lifestyle and risk factor management, plus counselling and psychological support.

What did we want to find out?

We wanted to find out if exercise-based rehabilitation was better than no exercise to improve:

- deaths

- hospital admission

- health-related quality of life

What did we do?

We searched for studies that assessed the effects of exercise-based cardiac rehabilitation in people with heart failure. We compared and summarised the results of relevant studies and rated our confidence in the evidence based on factors such as study methods and sizes.

What did we find?

We found 60 studies that involved 8728 people with heart failure. The studies were conducted in countries around the world. About 40% of the people came from 2 large studies. All studies lasted for around 6 months or longer.

Participation in exercise-based cardiac rehabilitation:

• likely reduces the risk of hospital admissions from any cause and due to heart failure up to 12 months from the start of the study;
• probably makes little to no difference in the risk of death from any cause;
• likely improves health-related quality of life as measured by the Minnesota Living with Heart Failure questionnaire.

The effects of exercise-based cardiac rehabilitation appear to be consistent:

• whether they are delivered in a hospital or medical centre, or are home-based;
• regardless of the amount of exercise or whether the programme also includes other components such as education or counselling;
• regardless of the type of training (just aerobic or aerobic plus resistance training).

What are the limitations of the evidence?

Our confidence in the evidence is limited because not all the studies used robust methods. Further studies are needed to assess the impact of alternative models of exercise-based rehabilitation relative to traditional centre-based programmes, especially home-based and digitally supported programmes. Future studies need to consider the generalisability of trial populations (women, older people, and people with heart failure with preserved ejection fraction remain under-represented in trial populations), the application of interventions to enhance long-term maintenance of exercise training and outcome, and costs.

How up to date is this evidence?

This review updates our previous 2018 review. The evidence is up to date to December 2021.

Authors' conclusions: 

This updated Cochrane review provides additional randomised evidence (16 trials) to support the conclusions of the previous 2018 version of the review. Compared to no exercise control, whilst there was no evidence of a difference in all-cause mortality in people with heart failure, ExCR participation likely reduces the risk of all-cause hospital admissions and heart failure-related hospital admissions, and may result in important improvements in HRQoL. Importantly, this updated review provides additional evidence supporting the use of alternative modes of ExCR delivery, including home-based and digitally-supported programmes. Future ExCR trials need to focus on the recruitment of traditionally less represented heart failure patient groups including older patients, women, and those with HFpEF.

Read the full abstract...

People with heart failure experience substantial disease burden that includes low exercise tolerance, poor health-related quality of life (HRQoL), increased risk of mortality and hospital admission, and high healthcare costs. The previous 2018 Cochrane review reported that exercise-based cardiac rehabilitation (ExCR) compared to no exercise control shows improvement in HRQoL and hospital admission amongst people with heart failure, as well as possible reduction in mortality over the longer term, and that these reductions appear to be consistent across patient and programme characteristics. Limitations noted by the authors of this previous Cochrane review include the following: (1) most trials were undertaken in patients with heart failure with reduced (< 45%) ejection fraction (HFrEF), and women, older people, and those with heart failure with preserved (≥ 45%) ejection fraction (HFpEF) were under-represented; and (2) most trials were undertaken in a hospital or centre-based setting.


To assess the effects of ExCR on mortality, hospital admission, and health-related quality of life of adults with heart failure.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO and Web of Science without language restriction on 13 December 2021. We also checked the bibliographies of included studies, identified relevant systematic reviews, and two clinical trials registers.

Selection criteria: 

We included randomised controlled trials (RCTs) that compared ExCR interventions (either exercise only or exercise as part of a comprehensive cardiac rehabilitation) with a follow-up of six months or longer versus a no-exercise control (e.g. usual medical care). The study population comprised adults (≥ 18 years) with heart failure - either HFrEF or HFpEF.

Data collection and analysis: 

We used standard Cochrane methods. Our primary outcomes were all-cause mortality, mortality due to heart failure, all-cause hospital admissions, heart failure-related hospital admissions, and HRQoL. Secondary outcomes were costs and cost-effectiveness. We used GRADE to assess the certainty of the evidence.

Main results: 

We included 60 trials (8728 participants) with a median of six months' follow-up. For this latest update, we identified 16 new trials (2945 new participants), in addition to the previously identified 44 trials (5783 existing participants). Although the existing evidence base predominantly includes patients with HFrEF, with New York Heart Association (NYHA) classes II and III receiving centre-based ExCR programmes, a growing body of trials includes patients with HFpEF with ExCR undertaken in a home-based setting. All included trials employed a usual care comparator with a formal no-exercise intervention as well as a wide range of active comparators, such as education, psychological intervention, or medical management. The overall risk of bias in the included trials was low or unclear, and we mostly downgraded the certainty of evidence of outcomes upon GRADE assessment.

There was no evidence of a difference in the short term (up to 12 months' follow-up) in the pooled risk of all-cause mortality when comparing ExCR versus usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.71 to 1.21; absolute effects 5.0% versus 5.8%; 34 trials, 36 comparisons, 3941 participants; low-certainty evidence). Only a few trials reported information on whether participants died due to heart failure. Participation in ExCR versus usual care likely reduced the risk of all-cause hospital admissions (RR 0.69, 95% CI 0.56 to 0.86; absolute effects 15.9% versus 23.8%; 23 trials, 24 comparisons, 2283 participants; moderate-certainty evidence) and heart failure-related hospital admissions (RR 0.82, 95% CI 0.49 to 1.35; absolute effects 5.6% versus 6.4%; 10 trials; 10 comparisons, 911 participants; moderate-certainty evidence) in the short term. Participation in ExCR likely improved short-term HRQoL as measured by the Minnesota Living with Heart Failure (MLWHF) questionnaire (lower scores indicate better HRQoL and a difference of 5 points or more indicates clinical importance; mean difference (MD) −7.39 points, 95% CI −10.30 to −4.77; 21 trials, 22 comparisons, 2699 participants; moderate-certainty evidence). When pooling HRQoL data measured by any questionnaire/scale, we found that ExCR may improve HRQoL in the short term, but the evidence is very uncertain (33 trials, 37 comparisons, 4769 participants; standardised mean difference (SMD) −0.52, 95% CI −0.70 to −0.34; very-low certainty evidence).

ExCR effects appeared to be consistent across different models of ExCR delivery: centre- versus home-based, exercise dose, exercise only versus comprehensive programmes, and aerobic training alone versus aerobic plus resistance programmes.