Strength Plus Aerobic Training Outperforms Aerobic Alone in HF

A new systematic review and meta-analysis appearing in the Journal of Sport and Health Science suggests that combining strength and aerobic exercise may offer greater improvements in physical function for patients with heart failure (HF) than aerobic training alone.¹

Exercise-based cardiac rehabilitation is already a cornerstone of HF management, with aerobic training widely recommended to improve cardiovascular fitness and outcomes.² However, the added value of incorporating muscle strength training into standard aerobic programs has remained uncertain.

In this new analysis, researchers evaluated 15 randomized controlled trials comprising 526 patients with HF, the majority of whom had HF with reduced ejection fraction (HFrEF). The study compared outcomes between patients undergoing aerobic training alone and those participating in combined programs that integrated strength training with aerobic exercise.

Patients who participated in combined training experienced significantly greater improvements in cardiorespiratory fitness (CRF), a critical predictor of survival HF. The analysis found a small-to-moderate but statistically significant improvement in CRF compared with aerobic training alone (standardized mean difference (SMD), 0.40; 95% CI, 0.10-0.71; P = .01), reinforcing the potential additive or synergistic effects of strength training.

“The greater increase in CRF observed with combined training may reflect a more prominent increase in skeletal muscle oxygen utilization in addition to a non-attenuated increase in cardiac function compared to AT alone,” wrote the researchers. “Our finding is in line with a previous systematic review demonstrating that muscle strength training increases CRF without changing LVEF.”

The new analysis showed that functional capacity also improved with combined training. In studies measuring the 6-minute walk test, a common indicator of real-world physical ability, patients in the combined training group walked nearly 50 meters farther on average than those performing aerobic exercise alone (mean difference (MD), 48.4 meters; 95% CI, 35.6-61.0 meters, P < .001).

Amongst strength training outcomes, upper body muscle strength improved significantly more in the combined training group (MD, 8.3 kg; 95% CI, 3.2-13.4 kg; P = .02), while lower body strength showed a trend toward improvement, though it did not reach statistical significance.

Importantly, the benefits of combined training were observed even when total exercise duration was matched between groups, meaning patients did not need to spend more time exercising to achieve greater improvements, only to adjust the balance of exercise types.

The study also explored the impact of different exercise intensities. Programs incorporating high-intensity interval training (HIIT) alongside strength training produced even greater improvements in cardiorespiratory fitness compared with HIIT alone (SMD, 0.68; 95% CI, 0.31-1.05; P = .003), suggesting that exercise intensity and modality may work together to optimize outcomes.

Despite these gains in physical performance, the analysis found no significant differences between groups in health-related quality of life or cardiac function measures such as ejection fraction. This suggests that while combined training improves how patients function, it may not directly translate into measurable changes in cardiac structure or patient-reported well-being, at least within the study timeframes, noted the researchers.

Adherence to exercise programs was generally high across both groups, with many studies reporting completion rates above 85%. Side effects were relatively infrequent and similar between groups, indicating that combined training is a safe and feasible option for most patients with heart failure.

However, the researchers cautioned that most of the included participants were male and had HFrEF, limiting the generalizability of the findings. Only one study included patients with heart failure with preserved ejection fraction (HFpEF), highlighting a significant gap in the evidence base. As a result, further research will be needed to determine whether the same benefits apply to broader patient populations, including women and those with different types of heart failure.

References

1. Terada T, Kambic T, Noda T, et al Combined strength and aerobic training vs. aerobic training alone in patients with heart failure: A systematic review and meta-analysis. J Sport Health Sci. Published online March 23, 2026. doi:10.1016/j.jshs.2026.101136

2. Mounsey LA, Guo M, Lau ES, Ho Je. Exercise training in heart failure: clinical benefits and mechanisms. Circ Res. Published online July 3, 2025. doi:10.1161/CIRCRESAHA.124.325533