Effectiveness of alternative exercises in cardiac rehabilitation on program completion and outcomes in women with or at high risk of cardiovascular disease: a systematic review and meta-analysis

Objective: This systematic review aimed to evaluate the effectiveness of alternative exercises within a cardiac rehabilitation (CR) program compared to traditional gym-based exercises or usual care. The focus was on CR completion and outcomes in women. Introduction: CR programs generally offer traditional gym-based exercises, including treadmill exercises, cycling on ergometers, and conventional resistance training. However, these exercises may not be suitable for all individuals, particularly women with chronic musculoskeletal conditions. Alternative exercises, such as yoga, Pilates, tai chi, Nordic walking, and dancing, have been suggested as safer and more enjoyable options, potentially increasing CR completion rates among women. However, the evidence on the effectiveness of alternative exercises in improving CR completion and other health outcomes for women remains limited. Inclusion criteria: This systematic review included randomized controlled trials evaluating the effects of alternative exercises in a CR program that recruited at least 50% women. Methods: The following databases were searched from inception to January 15, 2024: MEDLINE (Ovid), CINAHL (EBSCOhost), the Cochrane Central Register of Controlled Trials, Embase (Ovid), Emcare (Ovid), Scopus, Web of Science, LILACS, and PsycINFO (Ovid). Two reviewers independently assessed the methodological quality and certainty of evidence using the JBI critical appraisal instrument and Grading of Recommendations Assessment, Development and Evaluation (GRADE), respectively. Meta‐analyses with random-effects models were conducted for data synthesis. Results: Eight RCTs were included involving 398 women studied. Alternative exercises (yoga, tai chi, stepping exercises, Nordic walking, outdoor walking, and aerobic dance) had little to no effect on women’s CR completion compared to usual care (risk ratio [RR] 1.02; 95%CI 0.87–1.20; 2 trials; 51 participants; I2=0%, very low certainty of evidence). These alternative exercises may result in improved systolic blood pressure, diastolic blood pressure, body weight, and 6-minute-walk test at ≤12 weeks follow-up. Alternative exercises had little to no effect on other health outcomes, including body mass index, lipid profiles, fasting blood sugar, hemoglobin A1c, peak oxygen uptake, quality of life, and depression symptoms at ≤12 weeks. When examining longer-term impacts, it appears offering these modalities had little to no effect on blood pressure (systolic and diastolic) at 24 weeks. The evidence supporting these findings was rated as very low certainty for each outcome. Conclusions: Evidence on the effects of alternative exercises within CR on women’s CR completion and health outcomes remains limited. This is primarily due to the small number of trials involving women and the very low certainty of evidence for each outcome. Future well-designed RCTs are needed to provide more robust findings. Review registration: PROSPERO CRD42022354996