Running title: Baduanjin on Cardiac Rehabilitation After PCI

22 Abstract

23 Background

The effectiveness of Baduanjin for cardiac rehabilitation after percutaneous coronary

intervention (PCI), especially in Phase I and Phase II rehabilitation, remains

uncertain.

27 Objective

To systematically evaluate the effects of Baduanjin on cardiac rehabilitation outcomes

in patients after PCI.

30 Methods

Eight databases (CNKI, WanFang, VIP, SinoMed, PubMed, Web of Science,

EMBASE, and the Cochrane Library) were searched from inception to March 2026.

Only randomized controlled trials (RCTs) published in Chinese or English were

included. Meta-analyses were conducted using Stata/MP 18. This review was

prospectively registered in PROSPERO (CRD420251125740). Primary outcomes

were left ventricular ejection fraction (LVEF), six-minute walk test (6MWT), and

quality of life (QoL). Secondary outcomes included N-terminal pro-B-type natriuretic

peptide (NT-proBNP), left ventricular end-diastolic diameter (LVEDD), anxiety,

depression, mental health, physical functioning, social functioning, and adverse

events.

41 Result

Twenty-nine RCTs involving 3,031 patients were included. Compared with standard

care, Baduanjin significantly improved LVEF (WMD = 4.85, 95% CI: 2.23 to 7.47),

6MWT (WMD = 51.82, 95% CI: 19.81 to 83.84), and QoL (SMD = 2.33, 95% CI:

0.87 to 3.79), and significantly reduced NT-proBNP (SMD = -1.75, 95% CI: -2.75 to

-0.76), LVEDD (WMD = -3.96, 95% CI: -5.63 to -2.30), anxiety, depression, and

adverse events (RR = 0.39, 95% CI: 0.28 to 0.55). Significant improvements were

also observed in mental health, physical functioning, and social functioning. Benefits

appeared more consistent in Phase II rehabilitation.

50 Conclusion

Baduanjin appears to be a safe and promising complementary strategy for post-PCI

rehabilitation, although higher-quality RCTs are needed to confirm its effects.

Keywords: Baduanjin; Cardiac Rehabilitation; Percutaneous Coronary Intervention;

Meta-analysis; Randomized Controlled Trials

57 Introduction

Cardiovascular disease (CVD) is one of the leading causes of death and disability

worldwide (1). According to the Annual Report on Cardiovascular Health and

Diseases in China (2024), CVD remains the leading cause of death among both urban

and rural residents in China (2). In 2023, there were 8.368 million hospitalizations for

coronary heart disease (CHD), 1.222 million hospital admissions for acute myocardial

infarction (AMI), and 1.901 million patients with CHD underwent coronary

intervention; among these, PCI was the most performed procedure (2). As one of the

key revascularization strategies for CHD, PCI can effectively relieve coronary artery

stenosis or occlusion, improve myocardial ischemia, and reduce the risk of acute

cardiovascular events (3). However, PCI mainly addresses local perfusion problems,

and patients may still experience impaired cardiac function, limited exercise capacity,

increased psychological stress, and a higher risk of recurrence after the procedure.

Evidence has shown that, without systematic secondary prevention and rehabilitation

management, the rates of rehospitalization and mortality within 1 year after PCI

remain high (4).

Cardiac rehabilitation is a comprehensive intervention model based on

multidisciplinary collaboration, which includes exercise training, risk factor

management, nutritional counseling, psychological intervention, and health education.

A large body of evidence indicates that CR significantly improves cardiac function

and exercise tolerance, reduces rehospitalization and all-cause mortality, and

enhances quality of life (5). Consequently, the European Society of Cardiology

guidelines have recommended CR as a Class I intervention for patients after PCI (6).

In terms of rehabilitation stages, Phase I (in-hospital) focuses on complication

prevention and early functional recovery, while Phase II (early post-discharge)

emphasizes exercise capacity enhancement and lifestyle modification. Both stages are

crucial for improving long-term prognosis (7).

Baduanjin, a traditional Chinese exercise, has been widely applied in rehabilitation

due to its gentle movements, slow rhythm, and moderate intensity (8). Rooted in the

traditional Chinese medicine principle of “unity of body and mind,” it emphasizes the

coordination of physical movements with breathing techniques, thereby promoting the

circulation of qi and blood, harmonizing internal organs, and improving

cardiopulmonary function (9). Modern studies suggest that Baduanjin is not only a

safe and reliable form of aerobic exercise but also exerts regulatory effects on the

autonomic nervous system and neuroendocrine function, enhancing vagal activity and

improving cardiovascular status. Moreover, regular practice can increase patients’

rehabilitation motivation and adherence, alleviate anxiety and depression, and

consequently improve QoL (10). This mind-body integration distinguishes Baduanjin

from conventional exercise training, making it especially suitable for post-PCI

patients with reduced physical capacity who require a gradual recovery process. Thus,

incorporating Baduanjin into cardiac rehabilitation has significant research and

clinical application value.

However, the current evidence remains incomplete. Previous studies have often

focused on limited outcomes and have not comprehensively evaluated the effects of

Baduanjin on physiological, functional, psychological, and QoL outcomes after PCI.

Moreover, the potential differences in efficacy between Phase I and Phase II cardiac

rehabilitation remain unclear. Therefore, this systematic review and meta-analysis

aimed to comprehensively evaluate the effects of Baduanjin in patients after PCI and

to explore whether its efficacy differs between Phase I and Phase II cardiac

rehabilitation.

107

108 Methods

This systematic review and meta-analysis was conducted in accordance with the

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

guidelines (11). In addition, the study was prospectively registered in the PROSPERO

database (Registration No. CRD420251125740).

113

114 Inclusion and Exclusion Criteria

Inclusion criteria

Study population: Patients diagnosed with CHD, AMI, or acute coronary syndrome

(ACS) who had undergone PCI.

Interventions: Baduanjin exercise or sitting Baduanjin exercise.

Comparators: Standard care (such as assisted sitting for meals, turning in bed,

standing by the bedside, walking, and indoor ambulation, with exercise intensity

adjusted according to the patient’s physical condition).

Primary outcomes: LVEF, 6MWT, and QoL.

Secondary outcomes: NT-proBNP, LVEDD, anxiety, depression, mental health,

physical functioning, social functioning, and incidence of adverse events.

Study types: Only published RCTs in Chinese or English were included.

Exclusion criteria

Case series, surveys, letters, and studies without original data were excluded, as well

as duplicate publications.

129

130 Literature Search Strategy

The search strategy combined subject headings with free-text terms. In the Chinese

databases (CNKI, WanFang Database, VIP, and SinoMed), the following keywords

were used: “八段锦 (Baduanjin),” “八段锦运动 (Baduanjin exercise),” “健身气功

八段锦 (Health Qigong Baduanjin),” “坐式八段锦 (Seated Baduanjin),” “八段锦训

练 (Baduanjin training),” “八段锦运动疗法 (Baduanjin exercise therapy),” “中医八

段锦 (Traditional Chinese Medicine Baduanjin),” “ 经皮冠状动脉介入术

(Percutaneous Coronary Intervention),” “ 经皮冠脉介入术,” and “PCI.” In the

English databases (PubMed, Web of Science, EMBASE, and the Cochrane Library),

the following search terms were applied: “Baduanjin,” “BA-DUAN-JIN,” “Eight

Pieces of Brocade,” “Eight-Section Brocade,” “Eight Brocade,” “eight-section

exercise,” “Percutaneous Coronary Intervention,” “Coronary Intervention,

Percutaneous,” “Intervention, Percutaneous Coronary,” and “PCI.” A systematic

search was conducted for all relevant studies from the inception of each database up

to March 2026. The detailed search strategy is provided in Supplementary File 1.

145

146 Study Selection and Data Extraction

Study selection and data extraction were independently performed by two reviewers,

with cross-checking to ensure accuracy and completeness. Any disagreements were

resolved by a third reviewer. A database was established using Microsoft Excel to

extract the following information: first author and year of publication, sample size,

age range, study population characteristics, interventions (intervention/control groups),

and outcome measures. For studies reporting outcomes at multiple time points, it was

prespecified that only data assessed at the end of the Baduanjin intervention would be

included, in order to maintain consistency and comparability across studies.

155

156 Quality Assessment

Two reviewers independently assessed the methodological quality of the included

studies using the Cochrane Risk of Bias 2 (RoB 2) tool. Five domains were evaluated:

bias arising from the randomization process, bias due to deviations from intended

interventions, bias due to missing outcome data, bias in measurement of the outcome,

and bias in selection of the reported result. Each domain was judged as “low risk,”

“some concerns,” or “high risk,” and an overall risk-of-bias judgment was assigned

for each study. Discrepancies were resolved through discussion or, if necessary,

adjudicated by a third reviewer.

165

166 Certainty of evidence

The certainty of evidence for each outcome was assessed using the Grading of

Recommendations Assessment, Development and Evaluation (GRADE) approach.

Evidence from RCTs was initially rated as high certainty and could be downgraded by

one or two levels based on the following five domains: risk of bias, inconsistency,

indirectness, imprecision, and publication bias. The certainty of evidence was

categorized as high, moderate, low, or very low. Downgrading decisions were made

when serious or very serious concerns were identified in any domain, according to the

recommendations of the GRADE Working Group.

175

176 Statistical Analysis

Meta-analyses were performed using Stata/MP 18. Heterogeneity among studies was

assessed using the Cochrane Q test and the I² statistic. An I² value <50% was

considered to indicate low heterogeneity, in which case a fixed-effects model was

applied. When I² ≥50%, substantial heterogeneity was assumed, and a random-effects

model was adopted. Sensitivity analyses were further conducted to evaluate the

robustness of the results. Continuous variables were expressed as WMD or SMD with

95% CIs, while dichotomous variables were analyzed using RR as the effect measure.

Sensitivity analyses were performed by sequentially removing one study at a time to

examine the influence of individual studies on the overall results. A p-value <0.05

was considered statistically significant.

To explore potential sources of heterogeneity, exploratory meta-regression analyses

were performed for outcomes with sufficient data. Mean age was entered as a

continuous covariate, whereas intervention duration (<3 months vs. ≥3 months),

population category (CHD after PCI, AMI after PCI, and ACS after PCI), and

intervention type (Baduanjin exercise vs. sitting Baduanjin exercise) were entered as

categorical covariates. Random-effects meta-regression was conducted using REML

estimation.

194

195 Results

196 Literature Search

A total of 420 records were initially identified through eight databases. After

automatic and manual removal of 254 duplicates, 166 studies remained. Following a

preliminary screening of titles and abstracts, 124 studies were excluded for not

meeting the eligibility criteria. The remaining 42 articles underwent full-text review,

of which 29 met all inclusion criteria. The study selection process is illustrated in Fig

203

204 Fig 1. PRISMA flow diagram of the literature selection process.

205

206 Basic Characteristics of the Included Studies

A total of 29 studies involving 3,031 patients were included, comprising 1,515

patients in the intervention group and 1,516 patients in the control group. According

to the phase of cardiac rehabilitation, five studies focused on Phase I rehabilitation, of

which three studies enrolled patients with AMI (12-14) and two studies enrolled

patients with CHD (15, 16). The remaining 24 studies focused on Phase II

rehabilitation, including 10 studies that enrolled patients with AMI (17-26), 12 studies

that enrolled patients with CHD (27-38), and 2 studies that included patients with

ACS (39, 40). The interventions consisted of Baduanjin exercise or sitting Baduanjin

exercise, while control groups generally received usual care or routine rehabilitation.

The basic characteristics of the included studies are summarized in Table 1.

217

218 Quality Assessment

According to the RoB 2 assessment, most included studies were judged as having

some concerns in the randomization process, and only one study was rated as low risk

in this domain. For deviations from intended interventions, most studies were

assessed as low risk, although one study was judged as high risk and two studies were

rated as having some concerns. All studies were judged as low risk for missing

outcome data, measurement of the outcome, and selection of the reported result.

Overall, one study was rated as low risk of bias, one study was rated as high risk of

bias, and the remaining studies were judged as having some concerns. The

risk-of-bias assessment of the included studies is presented in Fig 2.

228

229 Fig 2. Risk-of-bias assessment of the included randomized controlled trials.

230

231 Results of Meta-Analysis

232 N-terminal pro-B-type Natriuretic Peptide (NT-proBNP)

Eight studies (n = 728) analyzed the effects of Baduanjin exercise on NT-proBNP

outcomes. Substantial heterogeneity was observed across the included studies (I² =

97.0%, p < 0.001); therefore, a random-effects model was applied. The pooled results

showed that Baduanjin exercise was associated with a significant reduction in

NT-proBNP compared with the control group (SMD = –1.75, 95% CI: –2.75 to –0.76).

Subgroup analysis by population category showed a significant reduction in the CHD

after PCI subgroup (SMD = –1.43, 95% CI: –2.75 to –0.12; I² = 95.4%), whereas no

statistically significant differences were observed in the ACS after PCI subgroup

(SMD = –3.53, 95% CI: –9.72 to 2.66; I² = 99.3%) or the AMI after PCI subgroup

(SMD = –0.98, 95% CI: –1.98 to 0.02; I² = 92.7%). (Fig 3A)

243

244 Fig 3. Forest plots for (A) NT-proBNP, (B) LVEF, (C) 6MWT, and (D) LVEDD.

245

246 Left Ventricular Ejection Fraction (LVEF)

Twenty studies (n = 1,950) analyzed the effects of Baduanjin exercise on LVEF

outcomes. Substantial heterogeneity was observed across the included studies (I² =

97.4%, p < 0.001); therefore, a random-effects model was applied. The pooled

analysis showed that Baduanjin exercise significantly improved LVEF compared with

the control group (WMD = 4.85, 95% CI: 2.23 to 7.47). Subgroup analysis by

population category showed significant improvements in the CHD after PCI subgroup

(WMD = 7.74, 95% CI: 4.46 to 11.02; I² = 95.1%) and the AMI after PCI subgroup

(WMD = 4.73, 95% CI: 1.33 to 8.12; I² = 97.3%), whereas no statistically significant

difference was observed in the ACS after PCI subgroup (WMD = –9.72, 95% CI:

–34.62 to 15.18; I² = 99.3%). (Fig 3B) Subgroup analysis by rehabilitation phase

showed a significant improvement in the Phase II subgroup (WMD = 5.08, 95% CI:

2.24 to 7.91; I² = 97.5%), whereas the Phase I subgroup did not reach statistical

significance (WMD = 2.27, 95% CI: –0.11 to 4.65; I² = 47.5%). (Supplementary File

261

262 Six-Minute Walk Test (6MWT)

Sixteen studies (n = 1,492) analyzed the effects of Baduanjin exercise on 6MWT

outcomes. Substantial heterogeneity was observed across the included studies (I² =

99.8%, p < 0.001); therefore, a random-effects model was applied. The pooled

analysis showed that Baduanjin exercise significantly improved 6MWT compared

with the control group (WMD = 51.82, 95% CI: 19.81 to 83.84). Subgroup analysis

by population category showed significant improvements in the CHD after PCI

subgroup (WMD = 70.41, 95% CI: 9.99 to 130.83; I² = 99.8%) and the AMI after PCI

subgroup (WMD = 46.80, 95% CI: 10.81 to 82.78; I² = 99.7%), whereas the ACS

after PCI subgroup included only one study and showed a significant decrease in

6MWT (WMD = –60.23, 95% CI: –68.09 to –52.37). (Fig 3C) Subgroup analysis by

rehabilitation phase showed a significant improvement in the Phase II subgroup

(WMD = 53.78, 95% CI: 18.67 to 88.89; I² = 99.8%), whereas the Phase I subgroup

did not reach statistical significance (WMD = 37.79, 95% CI: –5.86 to 81.44; I² =

97.1%). (Supplementary File 2)

277

278 Left Ventricular End-Diastolic Diameter (LVEDD)

Fourteen studies (n = 1,374) analyzed the effects of Baduanjin exercise on LVEDD

outcomes. Substantial heterogeneity was observed across the included studies (I² =

96.0%, p < 0.001); therefore, a random-effects model was applied. The pooled

analysis showed that Baduanjin exercise significantly reduced LVEDD compared

with the control group (WMD = –3.96, 95% CI: –5.63 to –2.30). Subgroup analysis

by population category showed significant reductions in the CHD after PCI subgroup

(WMD = –5.90, 95% CI: –8.07 to –3.74; I² = 80.2%) and the AMI after PCI subgroup

(WMD = –1.47, 95% CI: –2.88 to –0.06; I² = 92.2%), whereas the ACS after PCI

subgroup showed no statistically significant difference (WMD = –9.78, 95% CI:

–20.14 to 0.58; I² = 94.4%). (Fig 3D)

289

290 Quality of Life (QoL)

Six studies (n = 895) analyzed the effects of Baduanjin exercise on QoL outcomes.

Substantial heterogeneity was observed across the included studies (I² = 97.6%, p <

0.001); therefore, a random-effects model was applied. The pooled analysis showed

that Baduanjin exercise significantly improved QoL compared with the control group

(SMD = 2.33, 95% CI: 0.87 to 3.79). Subgroup analysis by population category

showed significant improvements in the AMI after PCI subgroup (SMD = 3.14, 95%

CI: 0.91 to 5.37; I² = 98.1%) and the CHD after PCI subgroup (SMD = 1.97, 95% CI:

0.59 to 3.34; I² = 93.8%). (Fig 4A) Subgroup analysis by rehabilitation phase showed

a significant improvement in the Phase II subgroup (SMD = 3.74, 95% CI: 1.35 to

6.13; I² = 98.4%), whereas the Phase I subgroup did not reach statistical significance

(SMD = 1.47, 95% CI: –0.30 to 3.24; I² = 96.0%). (Supplementary File 2)

302

303 Fig 4. Forest plots for (A) QoL, (B) anxiety, (C) depression, and (D) mental health.

304

305 Anxiety

Six studies (n = 669) analyzed the effects of Baduanjin exercise on anxiety outcomes.

Because substantial heterogeneity was observed (I² = 80.2%, p < 0.001), a

random-effects model was used. The pooled analysis showed that Baduanjin exercise

significantly reduced anxiety compared with the control group (SMD = –1.13, 95%

CI: –1.50 to –0.76). In subgroup analyses by population category, significant

reductions were observed in the CHD after PCI subgroup (SMD = –1.00, 95% CI:

–1.29 to –0.71; I² = 32.3%), the AMI after PCI subgroup (SMD = –1.07, 95% CI:

–2.12 to –0.03; I² = 93.8%), and the ACS after PCI subgroup (SMD = –1.65, 95% CI:

–2.13 to –1.18). (Fig 4B)

315

316 Depression

Six studies (n = 629) analyzed the effects of Baduanjin exercise on depression

outcomes. Because moderate heterogeneity was observed (I² = 46.4%, p = 0.097), a

fixed-effects model was used. The pooled analysis showed that Baduanjin exercise

significantly reduced depression compared with the control group (SMD = –1.30,

95% CI: –1.48 to –1.13). In subgroup analyses by population category, significant

reductions were observed in the CHD after PCI subgroup (SMD = –1.32, 95% CI:

–1.58 to –1.06; I² = 0.0%), the AMI after PCI subgroup (SMD = –1.22, 95% CI:

–1.48 to –0.95; I² = 85.8%), and the ACS after PCI subgroup (SMD = –1.51, 95% CI:

–1.98 to –1.05). (Fig 4C)

326

327 Mental Health

Six studies (n = 543) analyzed the effects of Baduanjin exercise on mental health

outcomes. Because substantial heterogeneity was observed (I² = 93.8%, p < 0.001), a

random-effects model was used. The pooled analysis showed that Baduanjin exercise

significantly improved mental health compared with the control group (SMD = 1.19,

95% CI: 0.43 to 1.95). In subgroup analyses by population category, significant

improvements were observed in the AMI after PCI subgroup (SMD = 1.25, 95% CI:

0.31 to 2.18; I² = 95.0%) and the CHD after PCI subgroup (SMD = 0.94, 95% CI:

0.47 to 1.41). (Fig 4D)

336

337 Physical Functioning

Seven studies (n = 653) analyzed the effects of Baduanjin exercise on physical

functioning outcomes. Because substantial heterogeneity was observed (I² = 92.9%, p

< 0.001), a random-effects model was used. The pooled analysis showed that

Baduanjin exercise significantly improved physical functioning compared with the

control group (SMD = 1.23, 95% CI: 0.58 to 1.87). In subgroup analyses by

population category, a significant improvement was observed in the AMI after PCI

subgroup (SMD = 1.44, 95% CI: 0.47 to 2.40; I² = 95.1%) and the CHD after PCI

subgroup (SMD = 0.77, 95% CI: 0.47 to 1.07; I² = 0.0%). (Fig 5A)

346

Fig 5. Forest plots for (A) physical functioning, (B) social functioning, and (C)

adverse events.

349

350 Social Functioning

Seven studies (n = 875) analyzed the effects of Baduanjin exercise on social

functioning outcomes. Because substantial heterogeneity was observed (I² = 93.6%, p

< 0.001), a random-effects model was used. The pooled analysis showed that

Baduanjin exercise significantly improved social functioning compared with the

control group (SMD = 1.03, 95% CI: 0.44 to 1.63). In subgroup analyses by

population category, a significant improvement was observed in the AMI after PCI

subgroup (SMD = 1.40, 95% CI: 0.33 to 2.47; I² = 94.5%), whereas the CHD after

PCI subgroup showed no statistically significant difference (SMD = 0.59, 95% CI:

–0.04 to 1.22; I² = 89.7%). (Fig 5B)

360

361 Incidence of Adverse Events

Eleven studies (n = 1,054) analyzed the effects of Baduanjin exercise on adverse

events. Because no significant heterogeneity was observed across the included studies

(I² = 0.0%, p = 0.845), a fixed-effects model was used. The pooled analysis showed

that Baduanjin exercise significantly reduced the risk of adverse events compared

with the control group (RR = 0.39, 95% CI: 0.28 to 0.55). In subgroup analyses by

population category, significant reductions were observed in the CHD after PCI

subgroup (RR = 0.28, 95% CI: 0.14 to 0.56; I² = 0.0%) and the AMI after PCI

subgroup (RR = 0.48, 95% CI: 0.32 to 0.70; I² = 0.0%), whereas the ACS after PCI

subgroup, based on a single study, showed no statistically significant difference (RR

371 = 0.16, 95% CI: 0.02 to 1.24). (Fig 5C)

372

373 Meta-Regression

Exploratory meta-regression was conducted for outcomes including more than 10

studies, with mean age, intervention duration, population category, and intervention

type entered as covariates. The results suggested that population category may be a

potential source of heterogeneity for LVEF, and a similar but weaker pattern was

observed for 6MWT, whereas no significant moderator was identified for LVEDD.

379 (Supplementary File 3)

380

381 GRADE Assessment

According to the GRADE approach, the certainty of evidence was rated as low for

most outcomes and moderate for adverse events. Low-certainty evidence was found

for NT-proBNP, LVEF, 6MWT, LVEDD, QoL, anxiety, depression, mental health,

physical functioning, and social functioning, whereas the certainty of evidence for

adverse events was moderate. Downgrading was mainly due to serious risk of bias,

largely related to inadequate reporting of allocation concealment and blinding, and

serious inconsistency resulting from substantial heterogeneity across studies.

389 (Supplementary File 4).

390

391 Sensitivity Analysis and Publication Bias

Sensitivity analysis was performed by sequentially excluding individual studies to

assess the influence of each study on the pooled effect estimates. The results showed

that all meta-analyses were stable and robust (Supplementary File 5). Publication

bias was assessed using both funnel plots and Egger’s test. The results of Egger’s test

(p = 0.432) indicated no significant publication bias (Supplementary File 6).

397

398 Discussion

This study systematically evaluated the effects of Baduanjin on multidimensional

rehabilitation outcomes in patients after PCI. Our pooled results showed that

Baduanjin improved LVEF, 6MWT, LVEDD, and QoL, while also reducing

NT-proBNP levels and the incidence of adverse events. Favorable effects were also

observed across several patient-centered domains, including anxiety, depression,

mental health, physical functioning, and social functioning. Collectively, these

findings support the potential value of Baduanjin as an adjunctive strategy in post-PCI

cardiac rehabilitation. More importantly, the contribution of our study lies not only in

confirming a beneficial role of Baduanjin, but also in expanding the scope of

evaluation beyond conventional rehabilitation endpoints. The review of Li et al. (41)

and Zhao et al. (42) mainly focused on cardiac function, exercise tolerance, quality of

life, and anxiety/depression, whereas our study additionally incorporated NT-proBNP,

adverse events, and more granular patient-centered outcomes, and further explored

differences between Phase I and Phase II cardiac rehabilitation.

Exercise training is a cornerstone of cardiac rehabilitation, and contemporary

guidelines consistently support structured rehabilitation for improving functional

status, quality of life, and selected clinical outcomes in patients after PCI and other

cardiovascular events (43, 44). In this context, Baduanjin, as a low- to

moderate-intensity mind–body exercise combining coordinated movement, breathing

regulation, and attentional control, is well aligned with the goals of exercise-based

rehabilitation. The increase in LVEF suggests a favorable effect on left ventricular

systolic function, which may be related to improved myocardial energy metabolism,

enhanced contractility, and optimized hemodynamic efficiency (45, 46). The

reduction in NT-proBNP further supports this interpretation, as NT-proBNP is a

well-established marker of myocardial wall stress, volume overload, and adverse heart

failure prognosis (47, 48). Likewise, the reduction in LVEDD suggests attenuation of

ventricular dilation and adverse remodeling, which are important for limiting

progression toward heart failure (49). The improvement in 6MWT indicates better

functional exercise capacity and cardiopulmonary reserve, suggesting that the benefits

of Baduanjin extend beyond echocardiographic measures to clinically relevant

physical recovery. From a clinical perspective, the magnitude of benefit may differ

across outcomes. Although the pooled improvement in LVEF was statistically

significant, an absolute increase of approximately 4.85% should be interpreted

cautiously and may be better viewed as a favorable directional change rather than

definitive evidence of a large clinical benefit, particularly given the known variability

of echocardiographic LVEF measurement (50). By contrast, the improvement in

6MWT may be more clinically interpretable, as previous studies have suggested a

minimal clinically important difference of about 25 m in patients with coronary artery

disease after acute coronary syndrome, and our pooled effect exceeded this threshold;

similarly, the reduction in adverse events is more directly patient-centered and

therefore more likely to be clinically meaningful (51).

Another important finding is that the benefits of Baduanjin appeared to be more

consistent in Phase II than in Phase I cardiac rehabilitation. We consider this

difference more likely to reflect variation in evidence maturity, patient stability, and

intervention intensity across rehabilitation stages than a true absence of effect in

Phase I. Phase I rehabilitation is usually delivered during the acute or in-hospital stage,

when patients are less stable, exercise tolerance is limited, and rehabilitation primarily

emphasizes early mobilization and complication prevention. By contrast, Phase II

rehabilitation is implemented in a more stable setting and usually allows

individualized exercise prescription, repeated training exposure, health education, and

longer follow-up, thereby making cumulative improvements in cardiac function and

exercise capacity more likely to emerge (52). In addition, the favorable effects

observed for anxiety, depression, mental health, physical functioning, and social

functioning suggest that Baduanjin may contribute to recovery not only through

general exercise effects, but also through its specific mind–body features, such as

breathing modulation, bodily relaxation, movement–attention coordination, and

emotional self-regulation (53, 54). These findings broaden the current understanding

of Baduanjin from conventional cardiac rehabilitation outcomes to a wider recovery

profile after PCI.

However, several limitations should be acknowledged. First, substantial heterogeneity

was present across most continuous outcomes, indicating between-study variation in

patient characteristics, disease spectrum, intervention delivery, training duration,

follow-up timing, outcome measurement, and diagnostic standards. In addition,

variations in exercise protocols across studies, including intervention form, frequency,

session duration, total duration, and implementation setting, may have contributed to

the observed heterogeneity and influenced the pooled results. Our exploratory

meta-regression suggested that population category may be a potential source of

heterogeneity for LVEF, with a similar but weaker pattern for 6MWT, whereas no

clear moderator was identified for LVEDD. Second, subgroup analyses for ACS and

Phase I rehabilitation were based on relatively few studies and should therefore be

interpreted cautiously. Third, all included studies were conducted in Chinese

populations, which limits the external generalizability of our findings to other ethnic,

cultural, and healthcare settings. Fourth, although all participants had undergone PCI,

the diagnostic guidelines and inclusion criteria for CHD, AMI, and ACS were not

fully uniform across studies, which may have further contributed to clinical

heterogeneity and reduced comparability. Finally, some included trials had relatively

small sample sizes and variable methodological quality, and the GRADE assessment

downgraded the certainty of evidence for several outcomes. Therefore, despite

generally robust sensitivity analyses and no significant publication bias detected by

Egger’s test, the overall certainty of inference remains limited. Future randomized

controlled trials with clearer phase definitions, standardized intervention protocols,

longer follow-up, and broader populations are needed to further define the true effect

of Baduanjin in post-PCI rehabilitation.

482

483 Conclusion

Overall, Baduanjin appears to be a safe, feasible, and clinically promising

complementary strategy for comprehensive rehabilitation after PCI; however, its true

effect size, underlying mechanisms, and optimal target populations still require

confirmation in well-designed randomized controlled trials.

488

489 Acknowledgments

490 None.

491

492 Conflict of Interest

493 The authors declare that the research was conducted in the absence of any commercial

494 or financial relationships that could be construed as a potential conflict of interest.

495

496 Author Contributions

Conceptualization, writing-original draft preparation: Shanshan Si; Writing-review

and editing: Yangjuan Bao, Hangfan Zhou, Yulian Huang; Methodology: Shanshan Si,

Yangjuan Bao, Jiuxin Ge, Hangfan Zhou, Yulian Huang; Resources: Shanshan Si,

Yangjuan Bao, Jiuxin Ge, Hangfan Zhou, Yulian Huang; Formal analysis and

investigation: Shanshan Si, Jiuxin Ge; Supervision: Jiuxin Ge.

502

503 Data Availability Statement

504 Data sharing is not applicable to this article as no datasets were generated or analysed

505 during the current study.

506

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687

688 Table 1. Basic Characteristics of the Included Studies.

Study	Year	Age Intervention	Control	N1	Intervention	N2	Control	Rehabilitation Phase	Population category
Xuejuan	2021	59.54±14.78	58.65±17.38	40	Baduanjin	40	Standard care	I	AMI after PCI
Wang
Juan Wang	2024	59.96±6.39	60.02±6.38	46	Baduanjin	46	Standard care	Ⅰ	AMI after PCI
Yu Cai	2022	49.58±9.41	49.47±9.32	45	Baduanjin	45	Standard care	Ⅰ	AMI after PCI
Hongmei Hu	2025	47.02±7.34	46.95±7.29	40	Baduanjin	40	Standard care	Ⅰ	CHD after PCI
Liang Kang	2024	52.2±10.9	53.0±10.7	60	Baduanjin	60	Standard care	Ⅱ	AMI after PCI
Xiaoyu	2023	53.8±14.2	52.4±13.6	60	Baduanjin	60	Standard care	Ⅱ	AMI after PCI
Zhang
Guoguo Liu	2022	56.21±10.44	57.32±11.36	30	Baduanjin	30	Standard care	Ⅱ	AMI after PCI
Hongyun	2023	57.44±7.32	56.38±7.31	45	Baduanjin	45	Standard care	Ⅱ	AMI after PCI

Zheng
Xuefei Liang	2022	59.9±11.9	61.2±10.2	24	Baduanjin	24	Standard care	II	AMI after PCI
Panpan Liu	2024	59.37±4.94	58.72±5.51	61	Baduanjin	61	Standard care	Ⅱ	AMI after PCI
Xing Wang	2023	52.0±16.7	52.5±15.5	40	Baduanjin	40	Standard care	Ⅱ	CHD after PCI
Ting Tang	2019	60.02±8.66	61.38±9.21	50	Baduanjin	50	Standard care	Ⅱ	CHD after PCI
Yingchun Du	2023	60.98±6.04	60.39±6.12	53	Baduanjin	53	Standard care	Ⅱ	CHD after PCI
Manzhen Wu	2024	64.27±4.61	64.74±4.57	51	Baduanjin	50	Standard care	Ⅱ	CHD after PCI
Miaomiao	2022	69.88±2.47	69.48±2.47	39	Baduanjin	39	Standard care	II	CHD after PCI
Gao
Yunxiao Cai	2022	58.42±6.61	59.02±6.78	37	Baduanjin	37	Standard care	Ⅱ	CHD after PCI
Tong Sun	2025	53.07±9.81	52.80±11.26	59	Baduanjin	60	Standard care	Ⅱ	CHD after PCI
Kai Zhao	2022	61.63±5.91	61.89±6.02	41	Baduanjin	41	Standard care	Ⅱ	CHD after PCI
Jinxin Zhao	2023	51.37±7.89	52.27±8.95	46	Baduanjin	47	Standard care	Ⅱ	ACS after PCI

Li Hua	2018	NA	NA	60	Sitting Baduanjin	60	Standard care	I	CHD after PCI
Jiamei Wang	2020	59.32±15.43	58.82±12.56	171	Sitting Baduanjin	171	Standard care	II	CHD after PCI
Yan Zhang	2021	60.48±13.28	65.53±13.23	40	Sitting Baduanjin	40	Standard care	II	CHD after PCI
Yueyan Yu	2022	61.13±11.06	60.4±11.37	53	Sitting Baduanjin	53	Standard care	II	AMI after PCI
Dan Zhang	2024	61.4±8.5	62.8±7.5	55	Sitting Baduanjin	55	Standard care	II	AMI after PCI
Zeyun Xu	2025	70.68±9.52	70.94±9.14	43	Sitting Baduanjin	43	Standard care	II	CHD after PCI
Yuying	2024	64.25±1.65	64.31±1.71	38	Sitting Baduanjin	38	Standard care	II	AMI after PCI
Huang
Rui Si	2025	59.68±5.93	60.26±6.14	73	Sitting Baduanjin	73	Standard care	II	AMI after PCI
Chenchen Hu	2023	57.16±5.28	56.84±6.27	60	Sitting Baduanjin	60	Standard care	II	ACS after PCI
Jingjing	2019	58.32±9.74	60.32±7.23	55	Sitting Baduanjin	55	Standard care	II	CHD after PCI
Wang

689

690 Supplementary Materials

Supplementary File 1: Search Strategy.

Supplementary File 2: Forest plot of subgroup analysis (rehabilitation phase).

Supplementary File 3: Results of Meta-Regression.

Supplementary File 4: GRADE Evidence Profile for Major Outcomes.

Supplementary File 5: Results of Sensitivity analysis.

Supplementary File 6: Results of Publication Bias.

Effects of Baduanjin Exercise on Phase I and II Cardiac Rehabilitation and Quality of Life in Patients After Percutaneous Coronary Intervention: A Systematic Review and Meta-Analysis