Front-loaded and mixed delivery models in hybrid cardiac rehabilitation: a systematic review and meta-analysis
- 1Faculty of Sports and Exercise Science, Universiti Malaya, Kuala Lumpur, Malaysia
- 2Department of Health, Sport, and Human Physiology, University of Iowa, Iowa City, USA
- 3Department of Rehabilitation Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
Abstract
Background: Traditional centre-based cardiac rehabilitation (CBCR) reduces cardiovascular mortality but suffers from suboptimal participation due to logistical barriers. Hybrid cardiac rehabilitation (Hybrid CR) has emerged as a flexible alternative, yet previous reviews have treated it as a monolithic intervention. This study evaluated the comparative effectiveness of Hybrid CR versus CBCR, stratified by delivery model structure: “front-loaded” (initial intensive centre-based block) versus “mixed” (concurrent alternating sessions).
Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing Hybrid CR with CBCR. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, and EMBASE were searched through October 2025. Outcomes included functional capacity (peak exercise oxygen uptake, VO₂peak; metabolic equivalents, METs; 6-minute walk distance), Health-Related Quality of Life (HRQoL), program attrition, and cardiovascular risk factors. Data were pooled using random-effects models.
Results: Twelve RCTs (n = 1,383) met the inclusion criteria. Hybrid CR showed no statistically significant difference compared with CBCR for functional capacity (Hedges’ g = 0.13, 95% CI -0.02 to 0.27; p = 0.09). Subgroup analysis showed no statistically significant differences for both front-loaded (g = 0.16) and mixed (g = 0.07) models. Program attrition did not differ significantly between groups (log RR = 0.03, p = 0.44). No significant differences were observed for lipid profiles or blood pressure. While overall HRQoL was similar between hybrid CR and CBCR, a mixed-model subgroup represented by a single study showed lower HRQoL compared with CBCR (g = − 0.86), identifying a potentially important outcome pattern that requires confirmation in additional studies. The certainty of evidence varied by outcome and was high for 6-minute walk distance, low for peak oxygen uptake, and very low for HRQoL and cardiometabolic outcomes.
Conclusions: Hybrid CR showed functional-capacity outcomes comparable to traditional CBCR, with no statistically significant differences observed between front-loaded and mixed delivery structures. However, certainty of evidence varied across outcomes and was limited for several secondary outcomes, particularly HRQoL and cardiometabolic measures. Further high-quality trials are needed to confirm whether specific hybrid delivery structures offer differential benefits.
PROSPERO registration: CRD420251170627.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12872-026-06388-2.
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BibTeX
@article{li2026frontloaded,
title = {{Front-loaded and mixed delivery models in hybrid cardiac rehabilitation: a systematic review and meta-analysis}},
author = {Runhao Li and Zhe Zhang and Gary L. Pierce and Anwar Bin Suhaimi and Selina Khoo},
journal = {BMC Cardiovascular Disorders},
year = {2026},
month = aug,
doi = {10.1186/s12872-026-06388-2},
url = {https://doi.org/10.1186/s12872-026-06388-2},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Front-loaded and mixed delivery models in hybrid cardiac rehabilitation: a systematic review and meta-analysis
AU - Runhao Li
AU - Zhe Zhang
AU - Gary L. Pierce
AU - Anwar Bin Suhaimi
AU - Selina Khoo
PY - 2026
DA - 2026/08/08
JO - BMC Cardiovascular Disorders
DO - 10.1186/s12872-026-06388-2
UR - https://doi.org/10.1186/s12872-026-06388-2
AB - Background: Traditional centre-based cardiac rehabilitation (CBCR) reduces cardiovascular mortality but suffers from suboptimal participation due to logistical barriers. Hybrid cardiac rehabilitation (Hybrid CR) has emerged as a flexible alternative, yet previous reviews have treated it as a monolithic intervention. This study evaluated the comparative effectiveness of Hybrid CR versus CBCR, stratified by delivery model structure: “front-loaded” (initial intensive centre-based block) versus “mixed” (concurrent alternating sessions). Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing Hybrid CR with CBCR. PubMed/MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, and EMBASE were searched through October 2025. Outcomes included functional capacity (peak exercise oxygen uptake, VO₂peak; metabolic equivalents, METs; 6-minute walk distance), Health-Related Quality of Life (HRQoL), program attrition, and cardiovascular risk factors. Data were pooled using random-effects models. Results: Twelve RCTs (n = 1,383) met the inclusion criteria. Hybrid CR showed no statistically significant difference compared with CBCR for functional capacity (Hedges’ g = 0.13, 95% CI -0.02 to 0.27; p = 0.09). Subgroup analysis showed no statistically significant differences for both front-loaded (g = 0.16) and mixed (g = 0.07) models. Program attrition did not differ significantly between groups (log RR = 0.03, p = 0.44). No significant differences were observed for lipid profiles or blood pressure. While overall HRQoL was similar between hybrid CR and CBCR, a mixed-model subgroup represented by a single study showed lower HRQoL compared with CBCR (g = − 0.86), identifying a potentially important outcome pattern that requires confirmation in additional studies. The certainty of evidence varied by outcome and was high for 6-minute walk distance, low for peak oxygen uptake, and very low for HRQoL and cardiometabolic outcomes. Conclusions: Hybrid CR showed functional-capacity outcomes comparable to traditional CBCR, with no statistically significant differences observed between front-loaded and mixed delivery structures. However, certainty of evidence varied across outcomes and was limited for several secondary outcomes, particularly HRQoL and cardiometabolic measures. Further high-quality trials are needed to confirm whether specific hybrid delivery structures offer differential benefits. PROSPERO registration: CRD420251170627. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1186/s12872-026-06388-2.
SN - 1471-2261
ER -