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Front-loaded and mixed delivery models in hybrid cardiac rehabilitation: a systematic review and meta-analysis
Journal article   Open access   Peer reviewed

Front-loaded and mixed delivery models in hybrid cardiac rehabilitation: a systematic review and meta-analysis

Runhao Li, Zhe Zhang, Gary L. Pierce, Anwar Bin Suhaimi and Selina Khoo
BMC cardiovascular disorders
08/08/2026
DOI: 10.1186/s12872-026-06388-2
url
https://doi.org/10.1186/s12872-026-06388-2View
Published (Version of record) Open Access

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.

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