Key messages
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Compared with no structured exercise, exercise-based cardiac rehabilitation for people with coronary heart disease reduces heart attacks, likely reduces hospital admissions and may slightly reduce the risk of death.
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Exercise is associated with improved well-being for up to 12 months and it appears to be cost-effective.
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Recent studies include more women, home-based and digital programmes, and more countries worldwide.
What is coronary heart disease?
Coronary heart disease (CHD) is a condition where the main blood vessels to the heart become narrow or blocked, often due to fatty deposits, reducing blood flow to the heart. It is the leading cause of death worldwide. Thanks to improvements in treatment, more people are now surviving CHD and living with its ongoing effects. Many people with CHD experience symptoms such as chest pain (angina) and breathlessness during physical activity, and fatigue. They may also be at risk of future complications, such as heart attacks.
What is exercise-based cardiac rehabilitation?
Exercise-based cardiac rehabilitation is designed to help people with CHD manage their condition, improve their health and reduce the risk of future problems. It includes structured exercise programmes, sometimes combined with education or psychological support.
What did we want to find out?
We wanted to find out if, compared to no structured exercise, people with CHD who participated in exercise-based cardiac rehabilitation had:
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a lower risk of death;
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fewer heart attacks;
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less need for further heart procedures (including stents (tiny tubes that hold the blood vessels open) or bypass surgery); and
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fewer hospital admissions.
We were also interested in whether exercise-based cardiac rehabilitation improved people's well-being and was cost-effective.
What did we do?
We searched for studies that investigated exercise-based cardiac rehabilitation compared to no structured exercise for adults with CHD. People in the studies had to have had a heart attack (myocardial infarction), surgery to restore blood flow to the heart (for example, a coronary artery bypass) or have angina or blocked arteries (coronary artery disease). Exercise could take place in a hospital, in the community, or in people's homes. Studies had to follow people for at least six months.
What did we find?
We found 107 studies with 26,886 people. Most people in these studies had experienced a heart attack or had received bypass surgery or a procedure to open narrowed or blocked blood vessels in the heart (angioplasty). Most studies included both men and women, but women made up only 17% of study participants overall.
Fifty-two studies investigated exercise only. The remaining studies investigated exercise combined with another treatment, such as education, or psychological or social support. The most common exercise was aerobic: static cycling; walking; or circuit training. The frequency and intensity of the exercise varied across studies. Twenty-seven studies looked at exercise in people's homes, with some programmes being delivered via a mobile phone app or online. Most studies followed people for up to 12 months.
Main results
Exercise-based cardiac rehabilitation for between six and 12 months compared with no structured exercise:
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probably reduces deaths from any cause (30 studies, 10,391 people) and may reduce deaths from heart-related causes (20 studies, 7277 people). For every 125 people who participate in exercise-based cardiac rehabilitation, one death from any cause is likely to be prevented. Similarly, for every 200 people participating, one death from heart-related causes may be prevented;
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results in a large reduction in heart attacks (25 studies, 8584 people). For every 71 people who participate in exercise-based cardiac rehabilitation, one heart attack is prevented;
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makes little to no difference to the need for further heart procedures (including stents or bypass surgery);
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probably reduces hospital admissions overall (21 studies, 3868 people) where for every 17 people who participate in exercise-based rehabilitation, one hospital admission is likely to be prevented. It may also reduce heart-related hospital admissions (6 studies, 1550 people).
The evidence indicated that people experienced increased well-being with exercise, compared with not participating in a structured exercise programme.
Based on evidence from eight studies, exercise-based cardiac rehabilitation was found to be cost-effective.
What are the limitations of this evidence?
We are very confident in the evidence for heart attack and the need for further heart procedures. However, our confidence in the other evidence is limited because some studies did not use the best methods to carry out their research or report their results. For example, we don't know how well people carried out their exercise programmes. Overall, there are still fewer women than men in the studies. However, many of the new studies that we found were carried out in low- and middle-income countries, so, our results may be more relevant than before for these countries.
How up-to-date is this evidence?
This updates the previous version published in 2021. The evidence is current to March 2026.
Read the full abstract
Background
Coronary heart disease (CHD) is the most common cause of death globally. However, with falling CHD mortality rates, an increasing number of people living with CHD may need support to manage their symptoms and prognosis. Exercise-based cardiac rehabilitation (CR) aims to improve the health and outcomes of people with CHD. This is an update of a Cochrane Review previously published in 2016.
Objectives
To assess the clinical and cost-effectiveness of exercise-based CR (exercise training alone or combined with psychosocial/educational interventions) compared with 'no exercise' control, on mortality, morbidity and health-related quality of life (HRQoL) in people with CHD.
Search strategy
We updated searches from the previous Cochrane review, searching CENTRAL, MEDLINE, Embase, Web of Science, CINAHL, and two clinical trials registers in March 2026.
Selection criteria
We included randomised controlled trials (RCTs) of exercise-based interventions with at least six months’ follow-up, compared with 'no exercise' control. The study population comprised adult men and women who have had a myocardial infarction (MI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI), or have angina pectoris, or coronary artery disease.
Data collection and analysis
We screened all identified references, extracted data and assessed risk of bias according to Cochrane methods. We stratified meta-analysis by duration of follow-up: short-term (6 to 12 months); medium-term (> 12 to 36 months); and long-term ( > 3 years), and used meta-regression to explore potential treatment effect modifiers. We used GRADE for primary outcomes at 6 to 12 months (the most common follow-up time point).
Main results
This review included 85 trials which randomised 23,430 people with CHD. This latest update identified 22 new trials (7795 participants). The population included predominantly post-MI and post-revascularisation patients, with a mean age ranging from 47 to 77 years.
In the last decade, the median percentage of women with CHD has increased from 11% to 17%, but females still account for a similarly small percentage of participants recruited overall ( < 15%). Twenty-one of the included trials were performed in low- and middle-income countries (LMICs). Overall trial reporting was poor, although there was evidence of an improvement in quality over the last decade. The median longest follow-up time was 12 months (range 6 months to 19 years).
At short-term follow-up (6 to 12 months), exercise-based CR likely results in a slight reduction in all-cause mortality (risk ratio (RR) 0.87, 95% confidence interval (CI) 0.73 to 1.04; 25 trials; moderate certainty evidence), a large reduction in MI (RR 0.72, 95% CI 0.55 to 0.93; 22 trials; number needed to treat for an additional beneficial outcome (NNTB) 75, 95% CI 47 to 298; high certainty evidence), and a large reduction in all-cause hospitalisation (RR 0.58, 95% CI 0.43 to 0.77; 14 trials; NNTB 12, 95% CI 9 to 21; moderate certainty evidence). Exercise-based CR likely results in little to no difference in risk of cardiovascular mortality (RR 0.88, 95% CI 0.68 to 1.14; 15 trials; moderate certainty evidence), CABG (RR 0.99, 95% CI 0.78 to 1.27; 20 trials; high certainty evidence), and PCI (RR 0.86, 95% CI 0.63 to 1.19; 13 trials; moderate certainty evidence) up to 12 months' follow-up. We are uncertain about the effects of exercise-based CR on cardiovascular hospitalisation, with a wide confidence interval including considerable benefit as well as harm (RR 0.80, 95% CI 0.41 to 1.59; low certainty evidence). There was evidence of substantial heterogeneity across trials for cardiovascular hospitalisations (I2 = 53%), and of small study bias for all-cause hospitalisation, but not for all other outcomes.
At medium-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.90, 95% CI 0.80 to 1.02; 15 trials), MI (RR 1.07, 95% CI 0.91 to 1.27; 12 trials), PCI (RR 0.96, 95% CI 0.69 to 1.35; 6 trials), CABG (RR 0.97, 95% CI 0.77 to 1.23; 9 trials), and all-cause hospitalisation (RR 0.92, 95% CI 0.82 to 1.03; 9 trials), a large reduction in cardiovascular mortality was found (RR 0.77, 95% CI 0.63 to 0.93; 5 trials). Evidence is uncertain for difference in risk of cardiovascular hospitalisation (RR 0.92, 95% CI 0.76 to 1.12; 3 trials).
At long-term follow-up, although there may be little to no difference in all-cause mortality (RR 0.91, 95% CI 0.75 to 1.10), exercise-based CR may result in a large reduction in cardiovascular mortality (RR 0.58, 95% CI 0.43 to 0.78; 8 trials) and MI (RR 0.67, 95% CI 0.50 to 0.90; 10 trials). Evidence is uncertain for CABG (RR 0.66, 95% CI 0.34 to 1.27; 4 trials), and PCI (RR 0.76, 95% CI 0.48 to 1.20; 3 trials).
Meta-regression showed benefits in outcomes were independent of CHD case mix, type of CR, exercise dose, follow-up length, publication year, CR setting, study location, sample size or risk of bias.
There was evidence that exercise-based CR may slightly increase HRQoL across several subscales (SF-36 mental component, physical functioning, physical performance, general health, vitality, social functioning and mental health scores) up to 12 months' follow-up; however, these may not be clinically important differences. The eight trial-based economic evaluation studies showed exercise-based CR to be a potentially cost-effective use of resources in terms of gain in quality-adjusted life years (QALYs).
Authors' conclusions
Compared with no exercise, exercise-based CR improves outcomes for people with CHD, including significantly reduced risk of MI and hospitalisation, a likely small reduction in all-cause and cardiovascular mortality, and improved HRQoL up to 12 months' follow-up. Over longer-term follow-up (> 12-months), exercise-based CR is associated with reduced cardiovascular mortality and MI. CR for people with CHD was also shown to be cost-effective. Recent trials have increased inclusion of women, used alternative models of CR delivery (home and digitally supported) and have been undertaken in LMICs, increasing the global generalisability of findings.
Funding
Internal sources: University of Glasgow, UK - funding support for the time of GD and RST. Radboud University Medical Centre, NL - funding support for the time of FdV, DT and NS.
External sources: past NIHR Cochrane Infrastructure funding to Cochrane Heart. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS or the Department of Health and Social Care.
Registration
Previous versions available via doi.org/10.1002/14651858.CD001800.pub4; doi.org/10.1002/14651858.CD001800.pub3; doi.org/10.1002/14651858.CD001800.pub2; doi.org/10.1002/14651858.CD001800; DOI 10.1016/j.amjmed.2004.01.009
