Exercise modalities and dose-response for LVEF Improvement in heart failure patients: a systematic review and network...

To compare the effects of various exercise modalities and doses on left ventricular ejection fraction (LVEF) in patients with heart failure.

We systematically searched eight electronic databases through December 2025. Randomized controlled trials involving adult HF patients were eligible. Interventions comprised aerobic exercise (AE), resistance training (RT), combined exercise (CE), mind-body exercise (ME), high-intensity interval training (HIIT), and control. Random-effects network meta-analysis was employed to estimate mean differences with 95% credible intervals, and surface under the cumulative ranking curve probabilities were calculated. Nonlinear dose-response relationships were modeled using MET-minutes per week.

42 RCTs comprising 3,519 participants were included. Network meta-analysis demonstrated that all exercise modalities significantly improved LVEF compared with control. Resistance training showed the largest treatment effect (MD: 9.9; 95% CrI: 6.5, 13.0), followed by HIIT (MD: 8.4; 95% CrI: 4.2, 12.0), CE (MD: 6.0; 95% CrI: 2.9, 9.0), and AE (MD: 5.2; 95% CrI: 3.3, 7.1). SUCRA rankings indicated RT had the highest probability of being optimal (93.1%), followed by HIIT (76.1%), ME (55.3%), CE (46.0%), and AE (29.5%). Dose-response analysis revealed a non-linear quadratic relationship between MET-minutes per week and LVEF improvement. The minimum effective dose was 280 MET-minutes/week, with the optimal dosage range of 500-800 MET-minutes/week. Modality-specific patterns emerged: RT produced benefits at low doses (220 MET-minutes/week; optimal 330-440), whereas HIIT required higher thresholds (440 MET-minutes/week; optimal 560-780). Evidence certainty ranged from very low to moderate across comparisons per CINeMA framework.

Resistance training is the most effective exercise modality for improving LVEF in HF patients, particularly at low-to-moderate doses. These findings support a precision-based rehabilitation strategy centered on RT to optimize cardiac function.

PROSPERO, CRD420261329239.