Comparative effects of exercise prescriptions on cardiac and functional outcomes in device-treated patients: a network meta-analysis

To compare the effects of different exercise prescriptions on cardiorespiratory fitness, exercise capacity, cardiac function, and health-related quality of life in patients receiving cardiac device therapy, and to provide evidence to guide individualized exercise-based rehabilitation in this population. PubMed, Embase, Web of Science, and the Cochrane Library were searched from inception to 1 March 2026. Randomized controlled trials enrolling adults treated with cardiac implantable electronic devices or left ventricular assist devices were eligible. Exercise interventions were classified by intensity, training structure, and exercise components as moderate-intensity continuous training (MICT), high-intensity interval training (HIIT), high-intensity continuous training (HICT), MICT combined with moderate-intensity resistance training (MICT-MIRT), or other combined training nodes. A random-effects network meta-analysis was performed. Treatment ranking was examined using the surface under the cumulative ranking curve (SUCRA), and the robustness and certainty of the evidence were assessed through sensitivity analyses, meta-regression, and the Confidence in Network Meta-Analysis (CINeMA) framework, based on Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles. Nineteen randomized controlled trials involving 984 patients receiving cardiac device therapy were included. Compared with standard of care, MICT, MICT-MIRT, and HIIT significantly improved peak oxygen uptake; MICT and MICT-MIRT significantly increased work rate; and HICT, MICT, and MICT-MIRT significantly prolonged exercise duration. MICT-MIRT significantly improved left ventricular ejection fraction, whereas MICT significantly reduced Minnesota Living with Heart Failure Questionnaire scores, indicating better health-related quality of life. For secondary outcomes, MICT and MICT-MIRT significantly increased anaerobic threshold. For 6-minute walk distance, VE/VCO₂ slope, resting heart rate, and respiratory exchange ratio, several interventions showed favorable trends, but no consistent or statistically robust differences were observed. Among outcomes with available CINeMA ratings, most network comparisons were supported by low- or very-low-certainty evidence, although selected comparisons for exercise duration and health-related quality of life reached moderate certainty. Structured exercise interventions may improve cardiorespiratory fitness, exercise capacity, selected cardiac functional indices, and health-related quality of life in patients receiving cardiac device therapy. On the basis of the available evidence, MICT showed directionally favorable effects across several outcomes, whereas MICT-MIRT showed potential benefits for left ventricular ejection fraction and selected exercise-capacity outcomes. These findings identify promising approaches rather than establishing a preferred exercise prescription, because most comparisons were supported by low- or very-low-certainty evidence and several networks were sparse. Larger multicenter head-to-head randomized trials with longer follow-up are warranted to clarify the comparative efficacy, safety, and patient-specific suitability of different exercise prescriptions.