Efficacy of acupuncture combined with exercise rehabilitation on cardiac function in patients with heart failure: a systematic review and meta-analysis

Background Exercise rehabilitation (ER) is recommended in both national and international guidelines for heart failure (HF). However, patients with severe symptoms may derive limited benefit from ER alone. Acupuncture has shown potential cardioprotective and symptom-relieving effects in some clinical studies, suggesting that acupuncture combined with exercise rehabilitation (ACER) may be a promising adjunctive strategy. This systematic review aimed to compare the efficacy of ACER with that of ER alone in patients with HF. Methods The Cochrane Library, PubMed, Ovid, Wanfang Medical Database, China Biomedical Literature Service (SinoMed), Weipu Database (VIP), China National Knowledge Infrastructure (CNKI), http://ClinicalTrials.gov , and the International Clinical Trials Registry Platform (ICTRP) were searched from inception to March 2026. This review followed the PRISMA statement and assessed evidence with GRADE. The aim was to identify randomized controlled trials (RCTs) investigating the effects of ACER on cardiac function in patients with HF. Two investigators independently screened studies, extracted relevant data, and assessed the methodological quality using the Risk of Bias version 2 tool (RoB 2). Meta-analyses were performed using RevMan 5.3. The protocol was registered in PROSPERO (CRD420251184719). Results Eight RCTs involving 668 patients were included, seven conducted in China and one in Serbia. Compared with ER alone, ACER was associated with statistically significant improvements in left ventricular ejection fraction [LVEFl; MD = 4.98, 95% CI (2.77, 7.18)], 6-min walk distance [6MWD; MD = 77.78 m, 95% CI (59.23, 96.32)], left ventricular end-systolic diameter (LVESD) [ MD = −5.27 mm, 95% CI (−7.83, −2.71)], Minnesota Living with Heart Failure Questionnaire (MLHFQ) score [ MD = −6.41, 95% CI (−7.71, −5.10)], and left ventricular end-diastolic diameter (LVEDD) [ MD = −5.65 mm, 95% CI (−6.81, −4.50)]. However, the certainty of the evidence was low or very low across all outcomes because of high risk of bias, substantial unexplained heterogeneity, imprecision, and uncertain publication bias. These findings should therefore be interpreted with extreme caution. Conclusion The current evidence is insufficient to determine whether ACER provides clinically meaningful benefits over ER alone in patients with HF. Further high-quality RCTs are needed before ACER can be recommended as an evidence-based adjunct in HF rehabilitation. Systematic review registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251184719 , identifier: CRD420251184719.