Effects of Virtual Reality–Based Interventions for Promoting Physical Activity in Patients With Heart Failure: Systematic Review

Background: Heart failure (HF) is a progressive chronic condition associated with reduced physical and functional capacity, psychological burden, cognitive decline, and diminished quality of life (QOL). Although exercise-based cardiac rehabilitation is beneficial, participation remains low due to accessibility, physical constraints, and motivational barriers. Virtual reality (VR)-based interventions, including immersive platforms and exergaming, may enhance accessibility and engagement and promote physical activity through interactive experiences. However, evidence regarding their effectiveness in patients with HF remains fragmented. Objective: This systematic review synthesized current evidence on the effects of VR-based interventions on physical activity, psychosocial outcomes, and self-management behaviors in patients with HF. Methods: We systematically searched PubMed, CINAHL, Embase, and Scopus for studies published within the past 10 years. Randomized controlled trials (RCTs) and non-RCT interventional studies involving adults with HF who participated in VR-based interventions were eligible. Outcomes included physical activity or exercise capacity, psychological well-being, self-management, and QOL. The reviewers screened articles, extracted data, and assessed risk of bias using version 2 of the Cochrane risk-of-bias tool for randomized trials for RCTs and the Risk of Bias in Nonrandomized Studies of Interventions tool for non-RCTs. The review adhered to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 and PRISMA-S (PRISMA extension for reporting literature searches) guidelines. Results: A total of 10 studies met the inclusion criteria, comprising 7 (70%) RCTs and 3 (30%) non-RCTs. Studies were conducted across multiple countries and predominantly included older adults (mean age ≥65 years). Most interventions were home based, with exergaming as the most frequent modality, followed by immersive VR cycling and digital coaching programs, delivered over 4 to 12 weeks. Across studies, VR-based interventions were associated with improvements in exercise capacity (n=6, 60% of the studies), physical activity (n=5, 50%), and QOL (n=4, 40%). Three of the studies (30%) reported reductions in depressive symptoms, whereas effects on anxiety and self-efficacy were inconsistent. Adherence and usability were high across studies, and no intervention-related adverse events were reported. However, the risk of bias was rated as "some concerns" or "high" in several domains, and heterogeneity in intervention design and outcome measurement, along with small samples, limited pooled synthesis and overall certainty of evidence. Conclusions: VR-based interventions show promise as accessible and engaging approaches to promote physical activity and support rehabilitation in patients with HF, particularly in home-based settings. Across the included studies, VR interventions were generally associated with improvements in exercise capacity, physical activity, QOL, and depressive symptoms, with high adherence and no reported safety concerns. However, interpretation is limited by heterogeneity in intervention design, small sample sizes, and methodological constraints. Future research should prioritize larger, rigorously designed trials to support sustained clinical impact.