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

Abstract

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). 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. 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. 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. CRD420251170627.