Long-term quality of life, rehospitalization risks, and economic viability of remote cardiac rehabilitation: an updated systematic review and meta-analysis

Background Although remote cardiac rehabilitation (RCR) is a promising alternative to traditional center-based care, evidence regarding its exact impact on health-related quality of life (HRQoL), cardiovascular safety, and economic viability remains fragmented, necessitating a comprehensive synthesis to guide clinical implementation. Objectives This systematic review and meta-analysis aim to evaluate the HRQoL, cardiovascular safety, and economic viability of RCR versus standard center-based care in cardiovascular disease, with subgroup analyses based on follow-up duration and high-risk patient cohorts. Methods Literature searches were conducted across multiple databases, including PubMed, Embase, and the Cochrane Library, supplemented by manual screening of relevant references to identify clinical studies on RCR up to July 2026. Two independent review teams performed data extraction and risk of bias assessment using the RevMan software. Meta-analyses were conducted employing random-effects models to calculate pooled effect sizes with corresponding 95% confidence intervals. Heterogeneity was assessed using the Cochrane Q test and I 2 statistic, and potential publication bias was evaluated using funnel plots and Egger's test. To evaluate the robustness of the pooled results and explore potential heterogeneity, subgroup and fixed-effects sensitivity analyses were conducted, supplemented by trial sequential analysis (TSA). Results A total of 45 randomized controlled trials were included in this meta-analysis. RCR significantly improved HRQoL across multiple scales (MacNew: MD = 0.17; MLHFQ: MD = −5.38; P < 0.05), while maintaining SF-36 and HADS outcomes comparable to standard care. Exploratory analyses indicated statistically significant improvements in mental health at 6 months (MD = 1.73, P = 0.03) and physical functioning at 12 months (MD = 1.48, P = 0.0002). Regarding cardiovascular safety, RCR was not associated with a statistically significant increase in the risk of MACEs, all-cause mortality, or adverse events ( P > 0.05) compared to conventional care. RCR significantly reduced the risk of cardiac rehospitalization (RR = 0.70, P = 0.01), with exploratory stratified analyses indicating that this favorable association was evident in the hardware-integrated interventions subgroup (RR = 0.59, P = 0.02) and 6-month observation subgroup (RR = 0.38, P < 0.00001), alongside a non-significant numerical protective trend among high-risk patients (RR: 0.59 vs. 0.74, P = 0.15). The economic viability of RCR remains uncertain, critically depending on initial setup outlays, patient scaling, and subsequent healthcare utilization. Conclusions RCR may serve as an effective and safe alternative to conventional care that improves physical and psychological well-being, was associated with a lower risk of cardiac rehospitalization, and may provide economic value in certain healthcare systems. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420261374977 , PROSPERO CRD420261374977.