Non-inferiority of virtual reality–based aerobic training compared with cycle ergometer and treadmill cardiac rehabilitation: a cardiopulmonary exercise testing analysis

Abstract

Virtual reality (VR)–based exercise has emerged as a novel modality for cardiac rehabilitation, but evidence comparing its physiological efficacy with conventional training methods remains limited. This study evaluated whether VR-based aerobic training is non-inferior to cycle ergometer and treadmill rehabilitation using cardiopulmonary exercise testing (CPET) outcomes.

In this prospective cohort study, 91 patients undergoing phase II cardiac rehabilitation were allocated to VR-based aerobic training (n=31), cycle ergometer (n=29), or treadmill exercise (n=31). All programs consisted of 12 supervised sessions. Primary outcome was change in peak oxygen consumption (ΔVO₂ peak). Secondary outcomes included ventilatory efficiency (VE/VCO₂ slope), anaerobic threshold VO₂, oxygen uptake efficiency slope (OUES), peak workload, symptom burden, adverse events, and rehospitalization at 6 months.

All groups demonstrated significant improvements in functional capacity. Mean ΔVO₂ peak was:VR: 2.28 ± 0.87 mL/kg/minCycle ergometer: 2.87 ± 1.05 mL/kg/minTreadmill: 2.93 ± 1.26 mL/kg/min

Improvements in ventilatory efficiency, anaerobic threshold, OUES, and peak workload were observed across all modalities with no clinically meaningful differences. Symptom scores decreased in all groups. No adverse events occurred during training. Rehospitalization rates at 6 months were low and comparable.

Non-inferiority of VR training was demonstrated for the primary endpoint within a clinically predefined margin.

Conclusions

VR-based aerobic rehabilitation provides improvements in functional capacity comparable to conventional cycle ergometer and treadmill training, without compromising safety. These findings support VR as a viable alternative modality for supervised cardiac rehabilitation programs.non- inferiority analysisDelta VO2 individual by modality