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Systematic Review

Effects of Exercise on Aerobic Capacity and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

by
Yin Liang
1,2,†,
Hao Su
2,†,
Ze Xu
2,
Xiaojie Liu
3,
Yuanyuan Lv
1,4,
Lin Feng
5,6,* and
Laikang Yu
1,2,*
1
Beijing Key Laboratory of Sports Performance and Skill Assessment, Beijing Sport University, Beijing 100084, China
2
Department of Strength and Conditioning Assessment and Monitoring, Beijing Sport University, Beijing 100084, China
3
Department of Pharmacology and Toxicology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
4
China Institute of Sport and Health Science, Beijing Sport University, Beijing 100084, China
5
School of Sport Sciences, Beijing Sport University, Beijing 100084, China
6
Beijing Sports Nutrition Engineering Research Center, Beijing 100084, China
*
Authors to whom correspondence should be addressed.
†
These authors have contributed equally to this work.
Appl. Sci. 2025, 15(10), 5393; https://doi.org/10.3390/app15105393
Submission received: 27 March 2025 / Revised: 29 April 2025 / Accepted: 6 May 2025 / Published: 12 May 2025
(This article belongs to the Special Issue The Impact of Sport and Exercise on Physical Health)
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Abstract

:
This study aimed to investigate the effects of exercise on aerobic capacity and quality of life (QOL) in heart failure (HF) patients and to identify the optimal exercise prescription for improving aerobic capacity and QOL. A comprehensive search was conducted in Embase, PubMed, Cochrane Library, Web of Science, and Scopus covering data published up to 9 October 2024. The Population, Intervention, Comparison, Outcome (PICO) framework was used to define the inclusion. (a) Population: patients with HF; (b) Intervention: randomized controlled trials (RCTs) with subjects randomly assigned to either the intervention or control group; (c) Comparison: studies that measured peak oxygen uptake (VO2peak), maximal oxygen uptake (VO2max), or the Minnesota Living with Heart Failure Questionnaire (MLHFQ) at baseline and compared results post-intervention; (d) Outcome: the primary outcomes were aerobic capacity and QOL. The Physiotherapy Evidence Database (PEDro) scale and the Cochrane Risk of Bias 2 (RoB-2) tool were used to assess the quality of the included studies. Weighted mean difference (WMD), standardized mean difference (SMD), and 95% confidence interval were used to pool data. A total of 47 studies met the inclusion criteria. Exercise significantly improved aerobic capacity (WMD, 2.85, p < 0.00001) and QOL (SMD, −0.79, p < 0.00001) in HF patients. Subgroup analyses indicated that combined exercise, session duration ≥ 60 min, ≥3 sessions per week, ≥180 min per week, and supervised exercise showed more significant improvements in aerobic capacity and QOL. Additionally, exercise had greater benefits in middle-aged patients. To improve aerobic capacity and QOL, the optimal exercise prescription for HF patients involves engaging in supervised combined exercise at least three times per week, with each session lasting at least 60 min, to achieve a total weekly duration of 180 min. These recommendations are particularly relevant for middle-aged patients, who may experience greater benefits from exercise interventions. The protocol has been registered on PROSPERO with the registration number CRD420250632915.

1. Introduction

Heart failure (HF) is a complex and debilitating cardiovascular syndrome, with its incidence and prevalence rising annually due to changes in lifestyle [1,2]. Based on ejection fraction and functional impairment, HF is categorized into heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF) [3]. Although these two types have different etiologies, they share highly similar clinical manifestations, such as reduced exercise tolerance, impaired neurohumoral regulation, and diminished cardiac pumping capacity [4,5,6]. Despite the availability of various pharmacological and non-pharmacological treatment strategies, patients with HF still experience exercise intolerance, excessive sympathetic activation (which is associated with poor prognosis), and reduced quality of life (QOL) [7,8]. It is alarming that over 23% of HF patients are rehospitalized within 60 to 90 days [9], and the survival rate is only 59% five years after the diagnosis of HF [10].
Reduced exercise capacity is a hallmark of HF patients, which can be attributed to factors such as endothelial dysfunction, decreased cardiac output, and autonomic nervous system dysregulation [11]. Exercise rehabilitation, as a non-pharmacological treatment approach, has been proven to be effective in reducing mortality and hospitalization rates among HF patients [12,13,14]. Exercise training offers numerous potential benefits, including improvements in peak oxygen uptake (VO2peak), central hemodynamics, peripheral vascular and skeletal muscle function, autonomic nervous system function, and overall functional capacity [15]. The European Society of Cardiology (ESC) guidelines recommend that HF patients engage in regular physical exercise, as it may help alleviate cardiac and muscular dysfunction [16]. Studies have demonstrated that exercise improves QOL by reducing sympathetic nervous excitability, enhancing vagal nerve activity, improving autonomic nervous function, and increasing aerobic capacity [17,18,19,20]. Additionally, exercise improves skeletal muscle endothelial function by enhancing peripheral blood flow and increasing the systemic arteriovenous oxygen difference [21], thereby enhancing aerobic capacity, reducing rehospitalization rates, and improving QOL [22,23].
Some researchers argue that improvements in aerobic capacity are primarily driven by peripheral adaptive changes, such as enhanced efficiency of oxygen delivery to active muscles [24], which also increases the potential for peripheral exercise training to improve exercise tolerance. However, not all studies support the positive effects of exercise on HF patients. For instance, a study by Wilson et al. [25] found that supervised training over three months did not improve VO2peak in HF patients. Similarly, another study focusing on elderly HF patients found that a six-month exercise program did not result in the anticipated improvements in VO2peak or six-minute walk distance [26]. These conflicting results may be related to the type of disease, the age of the subjects, and the specific exercise protocols employed.
Previous systematic reviews have shown that exercise-based cardiac rehabilitation improves QOL in HF patients compared with the control group that do not engage in exercise [27,28,29]. However, these reports have limitations. First, previous studies have primarily focused on patients with HFrEF. Given that HFpEF patients also experience exercise intolerance similar to that of HFrEF, the efficacy of exercise interventions in HFpEF warrants further investigation. Second, some studies only emphasized center-based rehabilitation, ignoring the potential benefits of home-based rehabilitation programs. Finally, the heterogeneity of the control group (e.g., inclusion of other exercise interventions) introduces uncertainty into the observed effects of the intervention. Therefore, the comprehensive impact of exercise on HF patients has not yet been fully assessed. Given the inconsistencies and limitations in the existing literature, the present study aims to explore the effects of exercise on aerobic capacity and QOL in HF patients in order to identify the optimal exercise modality for improving aerobic capacity and QOL.

2. Materials and Methods

2.1. Design

This study was conducted in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [30]. The protocol has been registered on PROSPERO with the registration number CRD420250632915.

2.2. Search Strategy

For this study, we searched the following databases: PubMed, Web of Science, Embase, Cochrane Library, and Scopus. The search included studies published from the inception of each database until 9 October 2024. We used the following keywords and MeSH terms to identify all studies on the effects of exercise on aerobic capacity and QOL in HF patients: exercise, heart failure, and randomized controlled trials (Table S1).

2.3. Eligibility Criteria

The Population, Intervention, Comparison, Outcome (PICO) framework was used to define the inclusion. (a) Population: patients with HF; (b) Intervention: randomized controlled trials (RCTs) with subjects randomly assigned to either the intervention or control group; (c) Comparison: studies that measured VO2peak, maximal oxygen uptake (VO2max), or the Minnesota Living with Heart Failure Questionnaire (MLHFQ) at baseline and compared results post-intervention; (d) Outcome: the primary outcomes were aerobic capacity and QOL.
The exclusion criteria were as follows: (1) non-English articles; (2) studies using animal models; (3) review articles; (4) conference abstracts; (5) studies with outcome measures that could not be converted to mean and standard deviation (SD). During the study selection process, we did not impose restrictions on the characteristics of the interventions or participants to avoid missing relevant studies.

2.4. Methodological Quality Assessment

Two authors independently assessed the quality of the included studies using the Physiotherapy Evidence Database (PEDro) scale and the Cochrane Risk of Bias 2 (RoB-2) tool. The PEDro scale, which consists of 11 items, is a tool designed to evaluate the quality of RCTs in physical therapy research [31]. According to the scoring criteria of the PEDro scale, a score below 4 indicates poor study quality, 4 to 5 indicates average quality, 6 to 8 indicates good quality, and a score above 9 indicates excellent quality [32]. The RoB2 tool comprises seven domains: (1) random sequence generation, (2) allocation concealment, (3) blinding of participants and personnel, (4) blinding of outcome assessment, (5) incomplete outcome data, (6) selective reporting, and (7) other biases [33]. Each domain was rated for risk of bias as “low”, “high”, or “unclear”. If disagreements arose between the two authors, a third author joined the discussion until consensus was reached among all three authors.

2.5. Data Extraction

Two authors independently extracted data from each study, including the following information: (1) study characteristics (surname of the first author, year of publication, sample size); (2) participant characteristics (age, type of disease); (3) intervention characteristics (type of intervention, duration of the intervention, frequency, session duration, weekly time, and supervision of the intervention); (4) changes in aerobic capacity and QOL. In the event of disagreement, a third author was consulted to achieve consensus.

2.6. Statistical Analysis

The mean values and SD of changes in VO2peak/VO2max and QOL before and after interventions were extracted from each study. When standard errors (SEs) were reported, SD was calculated through conversion [34]. Weighted mean difference (WMD), standardized mean difference (SMD), and 95% confidence intervals (CIs) were used to pool data on aerobic capacity and QOL. In cases of high heterogeneity (I2 > 50%), subgroup analysis and sensitivity analysis were conducted to interpret the results [35]. Publication bias of the included studies was assessed using funnel plots.
For subgroup analysis, the included studies were categorized based on various characteristics: intervention type (aerobic exercise, combined exercise), frequency (<3 sessions/week, ≥3 sessions/week), session duration (<60 min, ≥60 min), weekly time (<180 min, ≥180 min), supervision (supervised, self-supervised), and patient age (middle-aged: 45–59 years, elderly: ≥60 years). Forest plots were generated using RevMan 5.4 software (Cochrane, London, UK), while meta-regression, sensitivity analysis, and funnel plots were performed using Stata 17 (Stata Corp, College Station, TX, USA). Differences were considered statistically significant if p < 0.05.

3. Results

3.1. Study Selection

As shown in Figure 1, a search across five databases yielded 3389 relevant studies. After removing duplicates, 958 studies were excluded, and 2431 studies were assessed by reviewing titles and abstracts, leading to the exclusion of 2286 articles. Following a full-text evaluation of the remaining 145 articles, 98 studies were excluded primarily for the following reasons: (1) unclear data (n = 6); (2) participants not diagnosed with HF (n = 14); (3) non-exercise interventions (n = 3); (4) absence of a control group (n = 14); (5) inappropriate exercise protocols (n = 17); (6) lack of outcome measures (n = 4); and (7) conference articles (n = 40). Ultimately, 47 studies [34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78,79,80] were included in the meta-analysis.

3.2. Characteristics of the Included Studies

The primary characteristics of participants and intervention details are summarized in Table S2. The included studies comprised 1492 HF patients in the exercise groups and 1254 HF patients in the control groups. Across the various studies, the sample sizes ranged from 15 to 313 participants. The mean age of patients ranged from 48 to 77.6 years, with 16 studies involving patients whose mean age was between 45 and 59 years [36,37,47,49,50,51,52,54,57,62,64,70,77,78,79], and 19 studies involving patients with a mean age of 60 years or older [36,37,42,43,45,46,53,55,56,58,61,62,63,65,66,67,69,76,81].
Among the 47 included studies, 38 provided data on aerobic capacity [36,37,38,40,41,43,44,45,46,47,48,49,50,51,52,54,55,57,58,59,61,62,63,64,65,67,68,69,72,73,74,75,77,78,79,80,81,82], with one study measuring VO2max [68] and the remaining 37 studies assessing VO2peak. Additionally, 34 studies provided data on QOL [36,37,39,40,42,43,44,47,50,51,52,53,54,55,56,57,58,60,61,63,64,65,66,68,69,70,74,75,76,77,79,80,82], all of which were evaluated using the MLHFQ. In terms of intervention types, 26 studies involved aerobic exercise [37,38,40,41,43,44,45,46,48,51,53,54,55,56,57,58,59,60,63,65,67,69,72,75,78,82], two studies focused on resistance exercise [42,79], and 16 studies combined aerobic and resistance exercise [39,47,48,49,50,52,61,62,64,67,70,71,73,77,80,81]. Due to limited data on resistance exercise, it was not included in the subgroup analysis. The session duration ranged from 15 to 70 min, with an average of 47.6 min per session. The frequency varied from two to seven sessions per week, with an average of 3.2 sessions per week. The weekly time ranged from 90 to 300 min, with an average of 141.9 min. Finally, among the 47 included studies, 29 provided data on interventions conducted under medical supervision [36,37,38,39,41,42,44,46,48,49,50,52,54,55,56,58,61,63,64,65,67,68,74,75,76,77,78,80,82].

3.3. Meta-Analysis

The meta-analysis results indicated that exercise significantly improved aerobic capacity (WMD, 2.85; 95% CI, 2.18 to 3.52; p < 0.00001; I2 = 81%; Figure 2) and QOL in HF patients (SMD, −0.79; 95% CI, −0.97 to −0.62; p < 0.00001; I2 = 69%; Figure 3). To further investigate the heterogeneity among the included studies and identify more suitable exercise regimens for HF patients, subgroup analysis was conducted.

3.4. Subgroup Analysis

3.4.1. Aerobic Capacity

Subgroup analysis based on the intervention type revealed that both aerobic exercise (WMD, 2.33; 95% CI, 1.31 to 3.34; p < 0.00001; I2 = 80%) and combined exercise (WMD, 3.39; 95% CI, 2.03 to 4.75; p < 0.00001; I2 = 87%; Figure 4) significantly improved aerobic capacity in HF patients, with combined exercise demonstrating a greater improvement effect.
Additionally, interventions lasting less than 60 min (WMD, 2.07; 95% CI, 1.12 to 3.02; p < 0.0001; I2 = 73%) and those lasting 60 min or longer (WMD, 3.61; 95% CI, 2.53 to 4.69; p < 0.00001; I2 = 82%; Figure 5) significantly improved aerobic capacity in HF patients, with longer durations (≥60 min) showing superior effects.
Additionally, interventions with a frequency of at least three sessions per week (WMD, 2.97; 95% CI, 2.20 to 3.74; p < 0.00001; I2 = 83%) significantly improved aerobic capacity in HF patients, whereas interventions with fewer than three sessions per week did not show a significant improvement effect (WMD, 0.53; 95% CI, −1.03 to 2.09; p = 0.51; I2 = 7%; Figure 6).
Furthermore, interventions lasting less than 180 min per week (WMD, 2.15; 95% CI, 1.24 to 3.05; p < 0.00001; I2 = 70%) and those lasting 180 min or longer per week (WMD, 3.47; 95% CI, 2.19 to 4.76; p < 0.00001; I2 = 88%; Figure 7) significantly improved aerobic capacity in HF patients, with longer weekly time (≥180 min) showing greater improvement.
Moreover, supervised exercise significantly improved aerobic capacity in HF patients (WMD, 3.24; 95% CI, 2.53 to 3.94; p < 0.00001; I2 = 74%), while self-supervised exercise did not demonstrate a significant effect (WMD, 1.15; 95% CI, −0.41 to 2.71; p = 0.15; I2 = 80%, Figure 8).
Finally, exercise significantly improved aerobic capacity in both middle-aged (WMD, 3.28; 95% CI, 2.39 to 4.18; p < 0.00001; I2 = 76%) and elderly HF patients (WMD, 2.94; 95% CI, 1.67 to 4.21; p < 0.00001; I2 = 84%; Figure 9). Exercise had a greater effect on improving aerobic capacity in middle-aged HF patients.

3.4.2. QOL

Similarly, subgroup analyses based on the intervention type revealed that both aerobic exercise (SMD, −0.68; 95% CI, −0.90 to −0.46; p < 0.00001; I2 = 59%) and combined exercise (SMD, −0.91; 95% CI, −1.39 to −0.42; p = 0.0002; I2 = 82%; Figure 10) significantly improved QOL in HF patients, with combined exercise showing a greater effect.
Additionally, exercise interventions lasting less than 60 min (SMD, −0.82; 95% CI, −1.03 to −0.62; p < 0.00001; I2 = 53%) and those lasting 60 min or more (SMD, −0.95; 95% CI, −1.42 to −0.49; p < 0.0001; I2 = 80%; Figure 11) both significantly improved QOL in HF patients, with interventions lasting 60 min or more demonstrating a greater effect.
Moreover, interventions with a frequency of less than three times per week (SMD, −0.66; 95% CI, −1.04 to −0.29; p = 0.0005; I2 = 12%) and those with a frequency of three or more times per week (SMD, −0.83; 95% CI, −1.04 to −0.62; p < 0.00001; I2 = 72%; Figure 12) both significantly improved QOL in HF patients, with interventions occurring three or more times per week showing a greater improvement.
Furthermore, interventions lasting less than 180 min per week (SMD, −0.81; 95% CI, −1.00 to −0.62; p < 0.00001; I2 = 51%) and those lasting 180 min or more per week (SMD, −0.85; 95% CI, −1.25 to −0.45; p < 0.0001; I2 = 81%; Figure 13) both significantly improved QOL in HF patients, with interventions lasting 180 min or more per week demonstrating a greater effect.
Moreover, both supervised exercise (SMD, −0.97; 95% CI, −1.21 to −0.74; p < 0.00001; I2 = 69%) and self-supervised exercise (SMD, −0.43; 95% CI, −0.73 to −0.14; p = 0.004; I2 = 39%; Figure 14) significantly improved QOL in HF patients, with supervised exercise showing a greater effect.
Finally, exercise significantly improved QOL in both middle-aged (SMD, −0.88; 95% CI, −1.27 to −0.49; p < 0.0001; I2 = 80%) and elderly HF patients (SMD, −0.72; 95% CI, −0.94 to −0.50; p < 0.00001; I2 = 60%; Figure 15). Exercise had a greater effect on improving QOL in middle-aged HF patients.

3.5. Risk of Bias

The PEDro scale results showed that 31 studies were of good quality and 16 studies were of average quality (Table S3). The RoB-2 tool was used to assess the risk of bias, with studies categorized into three levels: low, moderate, and high risk. Among the 47 included studies, 46 were rated as moderate risk of bias and one was classified as high risk (Figure S1). Given the nature of exercise interventions, blinding of participants and personnel is often not feasible. Therefore, subjective factors may have introduced a degree of bias into the quality assessment process.

3.6. Publication Bias

To further assess potential publication bias, funnel plots were conducted. The funnel plot for aerobic capacity showed asymmetry (Figure S2). According to the results of the Egger’s test, publication bias was detected for this indicator (p = 0.001, Table S4). We applied the trim-and-fill method of Duval and Tweedie to correct for potential publication bias. The results of the trim-and-fill analysis still indicated that exercise had a significant positive effect on improving aerobic capacity in HF patients.
For QOL, the funnel plot showed relative symmetry (Figure S3), and the results of the Egger’s test indicated that small-study effects were not sufficient to influence the final results (p = 0.116, Table S4).

3.7. Sensitivity Analysis

The results of the sensitivity analysis showed that omitting any of the included studies did not change the overall direction or consistency of the effect of exercise on aerobic capacity (Figure S4) and QOL (Figure S5) in HF patients. This suggests that the findings of the meta-analysis are robust and not overly influenced by any single study.

4. Discussion

4.1. Main Findings

Our results demonstrated that exercise significantly improved both aerobic capacity and QOL in HF patients. Subgroup analyses indicated that combined exercise, particularly supervised exercise, lasting 60 min or more per session, performed at least three times per week, and totaling 180 min or more per week, was more effective in improving aerobic capacity and QOL, especially among middle-aged patients.

4.2. Effects of Exercise on Aerobic Capacity in HF Patients

This meta-analysis suggested exercise significantly improved aerobic capacity in HF patients. Extensive evidence indicates that in cardiovascular disease patients, improved aerobic capacity negatively correlates with all-cause mortality [83]. Previous studies have shown that high-intensity interval training, circuit resistance exercise, aquatic exercise, yoga, and Tai Chi significantly improved aerobic capacity in HF patients [84,85,86,87]. Similarly, Yamamoto et al. [88] also indicated that exercise had a significant positive effect on improving aerobic capacity in HF patients. However, Chen et al.’s [89] meta-analysis found that exercise did not significantly improve VO2peak in HF patients. Two factors may contribute to this difference. First, this meta-analysis included only three studies, and the sample size of three trials was relatively small. Second, among the included studies, two were performed before beta-adrenergic blockade became the main focus of therapy in HF. Our results are consistent with Yamamoto et al. [88], indicating that exercise plays a significant role in the rehabilitation of HF patients.
The mechanisms by which exercise improves aerobic capacity are multifaceted. First, exercise alleviates endothelial dysfunction in HF patients by increasing endothelial nitric oxide (NO) levels [90] and promoting angiogenesis and vascular repair [91]. Additionally, exercise improves left ventricular function and reverses cardiac remodeling [92,93] while reducing pro-inflammatory cytokines in the serum [94], which helps alleviate systemic metabolic imbalances and improve prognosis. Second, exercise positively impacts the autonomic nervous system. A 24-week exercise program significantly improved heart rate variability in stable chronic heart failure (CHF) patients [95]. Reducing sympathetic and renin–angiotensin system activity while enhancing vagal activity is crucial for improving exercise performance in HF patients.
Furthermore, exercise benefits the peripheral system. HF patients often suffer from severe peripheral system dysfunction, characterized by reduced skeletal muscle capillary density, decreased activity of mitochondrial oxidative enzymes such as cytochrome c oxidase and citrate synthase, and impaired oxygen uptake and transport in muscles. Moderate exercise increases blood flow and capillary density in skeletal muscles and promotes NO synthesis and release, thereby enhancing angiogenesis and reducing systemic peripheral resistance [96,97]. This process helps improve peripheral oxygen uptake and utilization, increases adenosine triphosphate (ATP) synthesis in skeletal muscle mitochondria, and ultimately enhances skeletal muscle function and exercise performance in patients [98,99].

4.3. Effects of Various Exercise Moderators on Aerobic Exercise Capacity in Patients with HF

Subgroup analysis revealed that both aerobic exercise and combined exercise significantly improved aerobic capacity in HF patients, with combined exercise being the most effective. Combined exercise leads to greater improvements in vascular function compared to aerobic exercise alone [100], likely due to its promotion of NO synthesis and enhanced enzyme activity. An 8-week combined exercise program not only improves VO2peak but also significantly increases lower limb muscle strength [101] and mitochondrial protein expression related to oxidative capacity [102]. Adding resistance exercise to aerobic exercise further improves the anaerobic threshold in HF patients [103]. Therefore, combined exercise enhances skeletal muscle oxidative capacity and vascular function, promoting further improvements in aerobic capacity.
Subgroup analyses of intervention characteristics revealed that both interventions shorter than 60 min and those lasting 60 min or more improved aerobic capacity in HF patients, with the latter demonstrating superior effects. A 20-week exercise intervention with 60-min sessions performed for three times per week significantly improves VO2peak in elderly HF patients [104]. Similarly, a 12-week combined exercise program with 60-minute sessions enhances 6-minute walking distance (6MWD) and QOL in CHF patients [105]. HF patients often develop a fear of physical activity due to exercise intolerance, leading to fat accumulation and even metabolic disorders. Prolonged exercise (>60 min) increases plasma free fatty acids utilization [106], reduces inflammation, and activates the aerobic metabolic system, improving cardiorespiratory endurance. However, the inclusion of slower-paced exercises like yoga and Tai Chi, which involve extended breathing and meditation, may influence the statistical effects of session duration, and thus results should be interpreted with caution.
Interventions performed at least three times per week significantly improved VO2peak in HF patients, while lower-frequency interventions do not. The American College of Sports Medicine (ACSM) recommends that healthy adults engage in low-to-moderate intensity exercise five times per week [107]. Studies have shown that cycling interventions performed five times per week significantly improve VO2peak in CHF patients [108], and 12-week walking programs performed five times per week significantly increases 6MWD in HF patients [109]. Previous studies have confirmed that an exercise frequency of three or more times per week is safe and effective in the HF population. For HF patients, more frequent exercise not only enhances treatment adherence and improves vascular health but also promotes positive changes in the nervous system [110].
Calculating weekly exercise time by combining session duration and frequency showed that programs with 180 min or more per week demonstrated more significant improvements in aerobic capacity than those with less than 180 min. The World Health Organization (WHO) recommends that healthy adults engage in 150–300 min of moderate-intensity exercise per week [111]. Studies support the positive impact of weekly time exceeding 180 min on cardiopulmonary function and metabolic capacity in HF patients [112,113]. However, daily exercise exceeding 180 min may cause excessive vagal activation and increase the risk of atrial fibrillation [114]. Therefore, combining a frequency of three or more sessions is recommended to achieve longer weekly time avoiding fatigue from excessively long sessions.

4.4. Effects of Exercise on QOL in HF Patients

The results of this study demonstrated that exercise significantly improved QOL in HF patients, consistent with previous findings [115]. A large-sample study found that both HFrEF and HFpEF patients experience severe QOL impairments, and therefore improving QOL is crucial for prolonging patient survival [116]. Previous studies have shown that exercise enhances aerobic capacity, alleviates depressive symptoms, boosts self-efficacy, and improves QOL in female HF patients [117], and Tai Chi effectively improves QOL in CHF patients [118].
One possible explanation for the impact of exercise on QOL is that it effectively enhances aerobic capacity and exercise efficiency, alleviates exercise intolerance, and enables patients to perform daily activities more easily, thereby improving self-efficacy and enhancing their ability to care for themselves. Additionally, improvements in exercise capacity can reduce hospital readmission rates and alleviate the economic burden on the healthcare system.

4.5. Effects of Various Exercise Moderators on QOL in HF Patients

Declines in cardiopulmonary function and muscle strength limit HF patients’ daily activities. Combined aerobic and resistance exercise significantly improves aerobic capacity and MLHFQ scores in HF patients [119], and combined exercise leads to more significant improvements in submaximal exercise capacity, muscle strength, and QOL compared to aerobic exercise alone [120]. Combined exercise effectively improves muscle strength and provides similar aerobic capacity benefits as aerobic exercise alone, which is significant for alleviating muscle strength intolerance in daily life and improving QOL.
Our subgroup analysis showed that exercise sessions lasting 60 min or more significantly improved QOL in HF patients, which is consistent with previous studies. A 12-week Tai Chi program with 60 min sessions improved MLHFQ scores and self-efficacy in patients with CHF [121], and long-duration (90–120 min) combined exercise significantly improved aerobic capacity, muscle strength, and reduced MLHFQ scores [122]. Prolonged light cycling exercise increased brain-derived neurotrophic factor (BDNF) levels and cognitive memory function [123], which is significant for HF patients’ prognosis. However, excessively long exercise sessions may cause injuries and diminish positive effects [124,125], while too short sessions may fail to achieve desired effects [126]. Future research should explore safe and effective exercise durations for HF patients.
Interventions performed at least three times per week significantly improved QOL in patients. A walking intervention performed three times per week improves exercise capacity, sleep duration, and reduces MLHFQ scores in elderly women with HFpEF [127], and a 9-week remotely supervised training program performed five times per week significantly improved VO2peak and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) scores in HF patients [128]. Regular and frequent exercise promotes a positive mindset and enhances self-management abilities. However, in practical applications, exercise performed less than three times per week may also yield some improvement effects, and its potential benefits remain worthy of attention.
The subgroup analysis results were similar to those for aerobic capacity, showing that both weekly times of less than 180 min and those of 180 min or more significantly improved QOL in HF patients. Specifically, exercise programs with a weekly time of 180 min or more demonstrated better improvement effects. Consistent with previous findings, Maiorana et al. [129] reported that a 180 min weekly combined exercise program significantly improved VO2peak and muscle strength in HFpEF patients. An expert consensus recommendation supports our findings, suggesting that HF patients gradually increase exercise frequency and duration to achieve a weekly goal of 300 min, thereby enhancing physical capacity and QOL [130]. Considering the target of 180 min or more of weekly exercise, this can be achieved by either increasing frequency or extending the session duration. However, for HF patients, taking into account safety and tolerance, increasing frequency may be a safer and more feasible option.
We conducted a subgroup analysis on whether the implementation of exercise programs was supervised by healthcare professionals. The results showed that supervised exercise led to better improvements in aerobic capacity and QOL in HF patients, which is consistent with a previous study [131], showing that outpatient-based supervised exercise programs significantly improved aerobic capacity and QOL in HFrEF patients. Additionally, McKelvie et al. [132] reported that 12 weeks of supervised exercise significantly improved VO2peak in HF patients, but this effect was not further enhanced during subsequent home-based exercise. The study also noted that patient adherence was higher in supervised settings, whereas adherence was suboptimal in self-supervised environments. Another RCT demonstrated that self-supervised home-based exercise rehabilitation programs for HF patients showed no significant differences in aerobic capacity and QOL compared to a non-exercise control group [133]. Therefore, even though self-supervised exercise may be less costly, patient adherence to the exercise regimen may be compromised. Recently, it has been reported that remotely supervised walking rehabilitation programs effectively improved cardiopulmonary function and QOL in HF patients [72]. Future research should further explore safer, more cost-effective, and efficient implementation methods.
To identify the sources of heterogeneity, we also conducted a subgroup analysis based on patient age. The results showed that exercise significantly improved aerobic capacity and QOL in both middle-aged and elderly patients, with better improvement observed in middle-aged patients. Elderly patients may have poorer exercise tolerance. A meta-analysis indicated that VO2peak did not significantly improve in elderly CHF patients after participating in exercise rehabilitation programs [89]. However, elderly individuals often suffer from comorbidities (e.g., arthritis, skeletal muscle atrophy), which may cause exercise limitations and restrict their ability to start with lower-intensity exercise, thereby affecting the magnitude of improvement in VO2peak [134]. Nevertheless, both middle-aged and elderly HF patients can benefit from exercise, and HF patients should initiate exercise rehabilitation as early as possible to improve prognosis.

4.6. Strength and Limitations

Our study contributes several strengths to the existing body of research on exercise and its effects on aerobic capacity and QOL in HF patients. First, our comprehensive meta-analysis includes a larger number of studies and participants than previous reviews, providing a more robust and reliable assessment of the overall effects. Additionally, we conducted subgroup analyses based on intervention type, frequency, session duration, weekly time, supervision, and patient age, which allowed us to identify specific conditions under which exercise prescription may be most effective. This level of detail enhances the applicability of our findings to HF patients.
This study also has several limitations that should be noted. First, some study protocols did not clearly describe the intensity of the exercise, resulting in insufficient statistical data to assess its impact on aerobic capacity and QOL. Second, intervention characteristics were analyzed independently, and univariate analysis cannot account for the interdependencies among these factors. Future research should employ more robust methods to comprehensively evaluate exercise programs’ factors. Third, subgroup analyses identified intervention type, session duration, frequency, supervision status, and participant age as primary sources of heterogeneity, but heterogeneity persisted within these subgroups. Finally, among the 47 included studies, 16 had a PEDro score below six, indicating the need for higher-quality studies to further understand the effects of exercise on aerobic capacity and QOL in HF patients.

5. Conclusions

The current meta-analysis demonstrates that combined exercise, particularly sessions lasting 60 min or more, performed at least three times per week, and totaling a minimum of 180 min per week, contributes to improvements in aerobic capacity and QOL in HF patients. Additionally, younger age and supervised exercise are associated with more significant improvements in aerobic capacity and QOL. These findings underscore the importance of structured, supervised exercise programs in the management of HF.
Based on our findings, we recommend that clinicians consider incorporating combined exercise programs into the rehabilitation plans for HF patients. Specifically, exercise sessions should be at least 60 min in duration, conducted at least three times per week, and total a minimum of 180 min per week. Supervised exercise programs may offer additional benefits, particularly for younger patients. Future research should focus on exploring optimal exercise protocols tailored to the specific needs of HF patients to maximize the benefits of exercise rehabilitation.

Supplementary Materials

The following supporting information can be downloaded at https://www.mdpi.com/article/10.3390/app15105393/s1. Figure S1: Results of Cochrane risk of bias tool; Figure S2: Funnel plot of aerobic capacity; Figure S3: Funnel plot of QOL; Figure S4: Sensitivity analysis results of aerobic capacity; Figure S5: Sensitivity analysis results of QOL; Table S1: Search strategies; Table S2: Characteristics of studies included in this meta-analysis; Table S3: Results of PEDro scale; Table S4: Results of Egger’s test.

Author Contributions

Conceptualization, Y.L. (Yin Liang) and L.Y.; methodology, Y.L. (Yin Liang), H.S. and L.F.; software, Y.L. (Yin Liang) and H.S.; validation, Z.X. and X.L.; formal analysis, Y.L. (Yin Liang) and H.S.; investigation, Y.L. (Yin Liang), H.S., Z.X., X.L. and Y.L. (Yuanyuan Lv); resources, L.Y.; data curation, Z.X. and Y.L. (Yuanyuan Lv); writing—original draft preparation, Y.L. (Yin Liang); writing—review and editing, Y.L. (Yin Liang), H.S., Z.X., X.L., Y.L. (Yuanyuan Lv), L.F. and L.Y.; visualization, Y.L. (Yin Liang) and H.S.; supervision, L.Y.; project administration, L.Y.; funding acquisition, L.Y. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the Humanities and Social Science Fund of the Ministry of Education of China, grant number 24YJC890065, and the Fundamental Research Funds for the Central Universities, grant number 2025KYPT05.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

All data generated or analyzed during this study are included in the article/Supplementary Materials.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
HFHeart failure
HFpEFHeart failure with preserved ejection fraction
HFrEFHeart failure with reduced ejection fraction
QOLQuality of life
VO2peakPeak oxygen uptake
ESCEuropean Society of Cardiology
PRISMAPreferred Reporting Items for Systematic Reviews and Meta-Analyses
RCTsRandomized controlled trials
VO2maxMaximal oxygen uptake
MLHFQMinnesota Living with Heart Failure Questionnaire
SDStandard deviation
PEDroPhysiotherapy Evidence Database
RoB-2Cochrane Risk of Bias 2
SEStandard error
WMDWeighted mean difference
SMDStandardized mean difference
CIConfidence interval
NONitric oxide
CHFChronic heart failure
ATPAdenosine triphosphate
6MWD6-minute walking distance
ACSMAmerican College of Sports Medicine
WHOWorld Health Organization
BDNFBrain-derived neurotrophic factor
SF-36Medical Outcomes Study 36-Item Short-Form Health Survey

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Figure 1. PRISMA flowchart of study selection.
Figure 1. PRISMA flowchart of study selection.
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Figure 2. Meta-analysis results of the effect of exercise on aerobic capacity in HF patients.
Figure 2. Meta-analysis results of the effect of exercise on aerobic capacity in HF patients.
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Figure 3. Meta-analysis results of the effect of exercise on QOL in HF patients.
Figure 3. Meta-analysis results of the effect of exercise on QOL in HF patients.
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Figure 4. Meta-analysis results of the effect of types of intervention on aerobic capacity in HF patients.
Figure 4. Meta-analysis results of the effect of types of intervention on aerobic capacity in HF patients.
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Figure 5. Meta-analysis results of the effect of duration of intervention per session on aerobic capacity in HF patients.
Figure 5. Meta-analysis results of the effect of duration of intervention per session on aerobic capacity in HF patients.
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Figure 6. Meta-analysis results of the effect of frequency of intervention on aerobic capacity in HF patients.
Figure 6. Meta-analysis results of the effect of frequency of intervention on aerobic capacity in HF patients.
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Figure 7. Meta-analysis results of the effect of duration of intervention per week on aerobic capacity in HF patients.
Figure 7. Meta-analysis results of the effect of duration of intervention per week on aerobic capacity in HF patients.
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Figure 8. Meta-analysis results of the effect of supervision status on aerobic capacity in HF patients.
Figure 8. Meta-analysis results of the effect of supervision status on aerobic capacity in HF patients.
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Figure 9. Meta-analysis results of the effect of different age groups on aerobic capacity in HF patients.
Figure 9. Meta-analysis results of the effect of different age groups on aerobic capacity in HF patients.
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Figure 10. Meta-analysis results of the effect of types of intervention on QOL in HF patients.
Figure 10. Meta-analysis results of the effect of types of intervention on QOL in HF patients.
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Figure 11. Meta-analysis results of the effect of duration of intervention per session on QOL in HF patients.
Figure 11. Meta-analysis results of the effect of duration of intervention per session on QOL in HF patients.
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Figure 12. Meta-analysis results of the effect of frequency of intervention on QOL in HF patients.
Figure 12. Meta-analysis results of the effect of frequency of intervention on QOL in HF patients.
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Figure 13. Meta-analysis results of the effect of duration of intervention per week on QOL in HF patients.
Figure 13. Meta-analysis results of the effect of duration of intervention per week on QOL in HF patients.
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Figure 14. Meta-analysis results of the effect of supervision status on QOL in HF patients.
Figure 14. Meta-analysis results of the effect of supervision status on QOL in HF patients.
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Figure 15. Meta-analysis results of the effect of different age groups on QOL in HF patients.
Figure 15. Meta-analysis results of the effect of different age groups on QOL in HF patients.
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MDPI and ACS Style

Liang, Y.; Su, H.; Xu, Z.; Liu, X.; Lv, Y.; Feng, L.; Yu, L. Effects of Exercise on Aerobic Capacity and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Appl. Sci. 2025, 15, 5393. https://doi.org/10.3390/app15105393

AMA Style

Liang Y, Su H, Xu Z, Liu X, Lv Y, Feng L, Yu L. Effects of Exercise on Aerobic Capacity and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Applied Sciences. 2025; 15(10):5393. https://doi.org/10.3390/app15105393

Chicago/Turabian Style

Liang, Yin, Hao Su, Ze Xu, Xiaojie Liu, Yuanyuan Lv, Lin Feng, and Laikang Yu. 2025. "Effects of Exercise on Aerobic Capacity and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials" Applied Sciences 15, no. 10: 5393. https://doi.org/10.3390/app15105393

APA Style

Liang, Y., Su, H., Xu, Z., Liu, X., Lv, Y., Feng, L., & Yu, L. (2025). Effects of Exercise on Aerobic Capacity and Quality of Life in People with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Applied Sciences, 15(10), 5393. https://doi.org/10.3390/app15105393

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