Cardiology · Medical Literature
Effects of Remote, Virtual, or Hybrid Cardiac Rehabilitation Supported by mHealth in Patients With Heart Failure: Systematic Review and Meta-Analysis.
Abstract
Structured exercise is a key component of cardiac rehabilitation (CR) for patients with heart failure (HF), but access to center-based cardiac rehabilitation (CBCR) is often limited. Mobile health (mHealth) platforms enable remote, virtual, or hybrid cardiac rehabilitation (RVH-CR) delivery. This study aimed to evaluate the effectiveness and safety of structured, exercise-focused RVH-CR supported by mHealth compared with usual care or CBCR in patients with heart failure with reduced ejection fraction (HFrEF) or in HF populations predominantly comprising patients with HFrEF. We searched PubMed, Web of Science, MEDLINE via Ovid, Cochrane CENTRAL, and CINAHL Complete from inception to April 27, 2026. Randomized controlled trials comparing mHealth-supported RVH-CR with usual care or CBCR were included. The primary outcome was exercise capacity, assessed by peak oxygen uptake (VO2 peak) and 6-minute walk distance (6MWD). Secondary outcomes included health-related quality of life and safety. Data were pooled using random-effects meta-analysis stratified by comparator. Risk of bias was assessed with the Cochrane Risk of Bias Tool version 2, and evidence certainty was evaluated using GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Eight randomized controlled trials with 1368 patients were included. In the CBCR comparison, mHealth-supported RVH-CR showed a statistically significant greater improvement in VO2 peak than CBCR (mean difference [MD] 0.82, 95% CI 0.06-1.57; P=.03), although this finding was based on a limited number of trials. Compared with usual care, mHealth-supported RVH-CR was associated with improved 6MWD (MD 22.99, 95% CI 1.15-44.82; P=.04). Single-trial estimates suggested improvements in VO2 peak (MD 2.50, 95% CI 0.88-4.12) and Minnesota Living with Heart Failure Questionnaire scores (standardized MD -0.57, 95% CI -0.98 to -0.17; P<.01) versus usual care. The certainty of evidence ranged from low to moderate. No intervention-related deaths or serious adverse events were reported, but sparse events and short follow-up limited conclusions regarding safety. The effects of structured RVH-CR supported by mHealth differed according to comparator type, but the certainty of evidence ranged from low to moderate. Compared with usual care, mHealth-supported RVH-CR was associated with improved 6MWD. Compared with CBCR, mHealth-supported RVH-CR showed a significantly greater improvement in VO2 peak in a limited number of trials, but superiority, equivalence, or noninferiority to CBCR cannot be concluded. Because usual care and CBCR are clinically distinct comparators, no single overall effect across comparator types should be inferred. Future studies should assess long-term outcomes and standardize structured exercise protocols across RVH-CR models.
Clinical relevance
Access to center-based cardiac rehabilitation (CBCR) remains a major barrier for patients with HFrEF, leaving a substantial proportion undertreated despite robust evidence for structured exercise. This systematic review and meta-analysis of 8 RCTs (n=1,368) is among the first to rigorously evaluate mHealth-supported remote, virtual, or hybrid CR (RVH-CR) specifically in HFrEF populations against both usual care and CBCR comparators. As mHealth platforms proliferate and value-based care models expand, cardiologists need current evidence to guide prescribing of digital CR pathways for this high-risk cohort.
Key findings
1. Compared with CBCR, mHealth-supported RVH-CR demonstrated a statistically significant greater improvement in VO2 peak (MD +0.82 mL/kg/min, 95% CI 0.06–1.57; P=.03), though this result was derived from a limited number of trials and must be interpreted with caution. 2. Compared with usual care, mHealth-supported RVH-CR was associated with a statistically significant improvement in 6-minute walk distance (MD +22.99 m, 95% CI 1.15–44.82; P=.04). 3. Single-trial estimates versus usual care suggested a clinically meaningful improvement in VO2 peak (MD +2.50 mL/kg/min, 95% CI 0.88–4.12), though these data are not yet pooled across multiple trials. 4. Health-related quality of life, measured by the Minnesota Living with Heart Failure Questionnaire, favored mHealth-supported RVH-CR over usual care in single-trial estimates (standardized MD -0.57, 95% CI -0.98 to -0.17; P<.01), indicating a moderate reduction in symptom burden. 5. No intervention-related deaths or serious adverse events were reported across included trials, supporting a preliminary favorable safety profile; however, sparse event data and short follow-up durations preclude definitive safety conclusions. 6. Overall certainty of evidence ranged from low to moderate per GRADE assessment, limiting the strength of recommendations that can be drawn from the current evidence base.
Practice implications
For HFrEF patients who cannot access or adhere to CBCR — including those with transportation barriers, geographic limitations, or functional constraints — mHealth-supported RVH-CR should be considered a clinically viable alternative, given demonstrated improvements in 6MWD versus usual care and comparable or superior VO2 peak gains versus CBCR. Clinicians should prioritize structured, exercise-focused protocols when prescribing RVH-CR via mHealth platforms, as unstructured digital engagement is unlikely to replicate the benefits observed in these RCTs. Given low-to-moderate evidence certainty, short follow-up periods, and the absence of standardized exercise protocols across trials, patients initiated on mHealth-supported RVH-CR should be enrolled in prospective registries or longer-term trials where feasible, and monitored for exercise adherence, functional trajectory, and safety signals beyond the acute intervention window.