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

Objective: To compare the effects of various exercise modalities and doses on left ventricular ejection fraction (LVEF) in patients with heart failure. Methods: 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. Results: 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. Conclusions: 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. Systematic Review Registration: PROSPERO, CRD420261329239.