Effects of combined high-intensity inspiratory muscle training and aerobic exercise in heart failure: a systematic review and meta-analysis.

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Abstract
Inspiratory muscle training (ΙμΤ) with high loads, an adjuvant exercise modality in cardiac rehabilitation programs, seems beneficial for patients with heart failure (HF). This systematic review and meta-analysis aims to investigate the effects of combined high ΙμΤ (H-IMT) and aerobic exercise (AE) training in patients with HF. A systematic search of randomized controlled trials (RCTs) was conducted across Medline (via EBSCOhost), PEDro, PubMed, Scopus, Web of Science up to 15 July 2025, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The revised Cochrane Risk of Bias tool for randomized trials (RoB2) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach were used to assess the methodological quality and overall evidence quality, respectively. A narrative synthesis of findings was completed, and meta-analysis was conducted on clinical outcomes when data were available from at least two studies. Seven RCTs were included, with female participants comprising 33% of the total sample. Interventions lasted from 6 to 16 weeks in hospital or home settings. Adding H-IMT elicits extra benefits in maximum inspiratory pressure (MIP) (MD = 15.24 cm H2O, 95% CI 7.30 to 23.17, P = 0.0002), quality of life (QoL) (MD = -6.96 units, 95% CI -11.33 to -2.59, P = 0.002) compared with AE training. No extra benefit was reported in pulmonary indices, left ventricular ejection fraction, aerobic and functional capacity. Still, most studies (4 out of 7) had a considerable risk of bias. Combined H-IMT and AE training may improve MIP and QoL in patients with HF. However, these findings are preliminary and based on very low-quality evidence. Larger, high-quality trials are needed to confirm benefits before broad clinical implementation. PROSPERO registration number is CRD42024568200.

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