{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T16:48:34Z","timestamp":1783529314102,"version":"3.55.0"},"reference-count":46,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T00:00:00Z","timestamp":1778803200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Peripheral muscle electrostimulation (PME), encompassing neuromuscular electrical stimulation (NMES) and functional electrical stimulation (FES), has been increasingly acknowledged as an effective adjunctive or complementary treatment to voluntary exercise in elderly cardiac patients who cannot perform sufficient amounts of exercise, for whom there is limited research on optimal protocols. Sarcopenia, defined as a progressive decrease in muscle mass, strength and function, affects approximately 34% of heart failure (HF) patients and considerably worsens their prognosis. The objective of this systematic review is to summarize current evidence on the theoretical mechanisms, physiological pathways, safety and efficacy of PME in older adults within a cardiac rehabilitation (CR) setting, with a specific emphasis on sarcopenia reversal. Methods: We performed a systematic review following the PRISMA 2020 guidelines. A systematic search was conducted on the PubMed, Embase, Cochrane Library, CINAHL and PEDro databases from inception until December 2025. We searched for randomized controlled trials (RCTs) and controlled clinical trials focusing on PME in patients with cardiac diseases aged 65 years or older. The main outcomes were physical function (assessed with the Short Physical Performance Battery [SPPB] and 6 min walk distance [6MWD]), muscle strength, muscle mass and safety. The Cochrane Risk of Bias tool was used to evaluate the quality of the studies. Results: Eight studies were included, with 387 participants and a mean age between 78 and 85 years. PME consistently improved lower-extremity muscle strength (MD: 5.2% body weight, 95% CI = 1.2\u20139.1, p = 0.013) along with SPPB scores, which ranged from +2.3 to +2.67 points (all p &lt; 0.05). Home-based PME (NMES) achieved 100% adherence rates, and no cardiovascular adverse events were reported. The mechanisms by which PME is beneficial involve peripheral skeletal muscle adaptations without eliciting central hemodynamic stress, increased endothelial function, aerobic enzyme activity, protein anabolism stimulation or muscle proteolysis inhibition. No significant effects were observed on BNP levels, hospital readmissions or mortality. PME has been shown to attenuate the progression of sarcopenia through hypertrophy of type I and II muscle fibers, as well as mitochondrial biogenesis. Conclusions: PME is a safe, feasible adjunct to conventional CR in frail, elderly cardiac patients, particularly those with exercise intolerance and sarcopenia. It improves peripheral muscle function, physical performance, and muscle protein balance without cardiovascular stress. Larger multicenter trials are needed to establish optimal protocols and long-term clinical outcomes.<\/jats:p>","DOI":"10.3390\/jcm15103826","type":"journal-article","created":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T14:19:29Z","timestamp":1778854769000},"page":"3826","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Theoretical and Scientific Underpinnings of Peripheral Muscle Electrostimulation in Cardiac Rehabilitation of the Elderly: A Systematic Review"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0004-9328-6219","authenticated-orcid":false,"given":"Damian","family":"Sendrowski","sequence":"first","affiliation":[{"name":"Institute of Health Sciences, Pomeranian University in S\u0142upsk, 76-200 S\u0142upsk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agata","family":"Pola\u0144ska-Szczap","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Janusz Korczak Voivodeship Regional Specialist Hospital in S\u0142upsk Ltd., 76-200 S\u0142upsk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Beata","family":"Hus","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Janusz Korczak Voivodeship Regional Specialist Hospital in S\u0142upsk Ltd., 76-200 S\u0142upsk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0000-1348-6861","authenticated-orcid":false,"given":"Anastasiia","family":"Vlaieva","sequence":"additional","affiliation":[{"name":"Department of Cardiology, Janusz Korczak Voivodeship Regional Specialist Hospital in S\u0142upsk Ltd., 76-200 S\u0142upsk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Szymon","family":"Markowski","sequence":"additional","affiliation":[{"name":"Wiemspro Polska, 43-384 Jaworze, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abraham","family":"Carl\u00e9-Calo","sequence":"additional","affiliation":[{"name":"Department of Physiology, Medicine Faculty, University of Granada, 18012 Granada, Spain"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dariusz","family":"Koz\u0142owski","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gda\u0144sk, 80-210 Gda\u0144sk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,5,15]]},"reference":[{"key":"ref_1","first-page":"CD003331","article-title":"Exercise-Based Cardiac Rehabilitation for Adults with Heart Failure","volume":"3","author":"Molloy","year":"2024","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1454","DOI":"10.1016\/j.jacc.2021.01.030","article-title":"Cardiac Rehabilitation for Patients with Heart Failure: JACC Expert Panel","volume":"77","author":"Bozkurt","year":"2021","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"873","DOI":"10.1161\/CIR.0b013e31829b5b44","article-title":"Exercise Standards for Testing and Training: A Scientific Statement from the American Heart Association","volume":"128","author":"Fletcher","year":"2013","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"e894","DOI":"10.1161\/CIR.0000000000000483","article-title":"Prioritizing Functional Capacity as a Principal End Point for Therapies Oriented to Older Adults with Cardiovascular Disease","volume":"135","author":"Forman","year":"2017","journal-title":"Circulation"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1161\/HHF.0000000000000005","article-title":"Heart Failure Management in Skilled Nursing Facilities: A Scientific Statement from the American Heart Association and the Heart Failure Society of America","volume":"8","author":"Jurgens","year":"2015","journal-title":"Circ. Heart Fail."},{"key":"ref_6","doi-asserted-by":"crossref","unstructured":"Curcio, F., Testa, G., Liguori, I., Papillo, M., Flocco, V., Panicara, V., Galizia, G., Della-Morte, D., Gargiulo, G., and Cacciatore, F. (2020). Sarcopenia and Heart Failure. Nutrients, 12.","DOI":"10.3390\/nu12010211"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"323","DOI":"10.1038\/nrcardio.2017.51","article-title":"Muscle Wasting and Cachexia in Heart Failure: Mechanisms and Therapies","volume":"14","author":"Ebner","year":"2017","journal-title":"Nat. Rev. Cardiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1580","DOI":"10.1002\/ejhf.1304","article-title":"Comparison of Sarcopenia and Cachexia in Men with Chronic Heart Failure: Results from the Studies Investigating Co-morbidities Aggravating Heart Failure (SICA-HF)","volume":"20","author":"Emami","year":"2018","journal-title":"Eur. J. Heart Fail."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1136\/heartjnl-2016-309995","article-title":"The Challenge of Frailty and Sarcopenia in Heart Failure with Preserved Ejection Fraction","volume":"103","author":"Kinugasa","year":"2017","journal-title":"Heart"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1093\/eurheartj\/ehs381","article-title":"Muscle Wasting in Patients with Chronic Heart Failure: Results from the Studies Investigating Co-Morbidities Aggravating Heart Failure (SICA-HF)","volume":"34","author":"Tacke","year":"2013","journal-title":"Eur. Heart J."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"373","DOI":"10.1016\/j.jtcvs.2016.09.036","article-title":"Neuromuscular Electrical Stimulation May Attenuate Muscle Proteolysis After Cardiovascular Surgery: A Preliminary Study","volume":"153","author":"Iwatsu","year":"2017","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"200","DOI":"10.1016\/j.ijcard.2016.09.127","article-title":"Neuromuscular Electrical Stimulation for Muscle Wasting in Heart Failure Patients","volume":"225","author":"Saitoh","year":"2016","journal-title":"Int. J. Cardiol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1093\/eurjpc\/zwaa117","article-title":"Impact of Sarcopenia on Prognosis in Patients with Heart Failure with Reduced and Preserved Ejection Fraction","volume":"28","author":"Konishi","year":"2021","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"16","DOI":"10.1093\/ageing\/afy169","article-title":"Sarcopenia: Revised European Consensus on Definition and Diagnosis","volume":"48","author":"Bahat","year":"2019","journal-title":"Age Ageing"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1253\/circrep.CR-24-0091","article-title":"Randomised Crossover Trial of Home-Based Neuromuscular Electrical Stimulation Therapy as an Adjunct to Cardiac Rehabilitation in Frail Older Adult Patients with Chronic Heart Failure","volume":"7","author":"Ono","year":"2025","journal-title":"Circ. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1163","DOI":"10.2147\/CIA.S460805","article-title":"Improving Lower Limb Function and Frailty in Frail Older Patients with Acute Myocardial Infarction After Percutaneous Coronary Intervention: A Randomized Controlled Study of Neuromuscular Electrical Stimulation","volume":"19","author":"Pu","year":"2024","journal-title":"Clin. Interv. Aging"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"44","DOI":"10.1378\/chest.08-2481","article-title":"Effects of Neuromuscular Electrical Stimulation of Muscles of Ambulation in Patients with Chronic Heart Failure or COPD","volume":"136","author":"Sillen","year":"2009","journal-title":"Chest"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"111402","DOI":"10.1016\/j.mad.2020.111402","article-title":"Molecular and Neural Adaptations to Neuromuscular Electrical Stimulation; Implications for Ageing Muscle","volume":"193","author":"Guo","year":"2021","journal-title":"Mech. Ageing Dev."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 Statement: An Updated Guideline for Reporting Systematic Reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1186\/s13643-020-01542-z","article-title":"PRISMA-S: An Extension to the PRISMA Statement for Reporting Literature Searches in Systematic Reviews","volume":"10","author":"Rethlefsen","year":"2021","journal-title":"Syst. Rev."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e078384","DOI":"10.1136\/bmj-2023-078384","article-title":"Guidance on Terminology, Application, and Reporting of Citation Searching: The TARCiS Statement","volume":"385","author":"Hirt","year":"2024","journal-title":"BMJ"},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Tong, A., Flemming, K., McInnes, E., Oliver, S., and Craig, J. (2012). Enhancing Transparency in Reporting the Synthesis of Qualitative Research: ENTREQ. BMC Med. Res. Methodol., 12.","DOI":"10.1186\/1471-2288-12-181"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Wan, X., Wang, W., Liu, J., and Tong, T. (2014). Estimating the Sample Mean and Standard Deviation from the Sample Size, Median, Range, and\/or Interquartile Range. BMC Med. Res. Methodol., 14.","DOI":"10.1186\/1471-2288-14-135"},{"key":"ref_24","doi-asserted-by":"crossref","unstructured":"Tanaka, S., Kamiya, K., Matsue, Y., Yonezawa, R., Saito, H., Hamazaki, N., Matsuzawa, R., Nozaki, K., Yamashita, M., and Wakaume, K. (2022). Efficacy and Safety of Acute Phase Intensive Electrical Muscle Stimulation in Frail Older Patients with Acute Heart Failure: Results from the ACTIVE-EMS Trial. J. Cardiovasc. Dev. Dis., 9.","DOI":"10.3390\/jcdd9040099"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1177\/02692155211056999","article-title":"The Effectiveness of Functional Electrical Stimulation of the Legs in Patients with Heart Failure: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","volume":"36","author":"Wang","year":"2022","journal-title":"Clin. Rehabil."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1097\/HCR.0000000000000151","article-title":"Effects of Neuromuscular Electrical Stimulation on Physiologic and Functional Measurements in Patients with Heart Failure: A Systematic Review with Meta-Analysis","volume":"36","author":"Oliveira","year":"2016","journal-title":"J. Cardiopulm. Rehabil. Prev."},{"key":"ref_27","unstructured":"EQUATOR Network (2026, April 10). Reporting Guidelines for Systematic Reviews and Meta-Analyses. Available online: https:\/\/www.equator-network.org\/reporting-guidelines-study-design\/systematic-reviews-and-meta-analyses\/."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"30","DOI":"10.1186\/s13054-016-1199-3","article-title":"Muscle Mass, Strength and Functional Outcomes in Critically Ill Patients After Cardiothoracic Surgery: Does Neuromuscular Electrical Stimulation Help? The Catastim 2 Randomized Controlled Trial","volume":"20","author":"Fischer","year":"2016","journal-title":"Crit. Care"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"831","DOI":"10.1177\/2047487314540546","article-title":"Efficacy and Safety of Functional Electrical Stimulation of Lower Limb Muscles in Elderly Patients with Chronic Heart Failure","volume":"22","author":"Karavidas","year":"2015","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"871","DOI":"10.1016\/S0195-668X(02)00822-9","article-title":"A Randomised Study of Home-Based Electrical Stimulation of the Legs and Conventional Bicycle Exercise Training for Patients with Chronic Heart Failure","volume":"24","author":"Harris","year":"2003","journal-title":"Eur. Heart J."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1274","DOI":"10.1177\/2047487317712601","article-title":"Effects of Combined Exercise Training and Electromyostimulation Treatments in Chronic Heart Failure: A Prospective Multicentre Study","volume":"24","author":"Iliou","year":"2017","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1016\/j.ijcard.2011.12.019","article-title":"Functional Electrical Stimulation for Chronic Heart Failure: A Meta-Analysis","volume":"167","author":"Smart","year":"2013","journal-title":"Int. J. Cardiol."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"1521","DOI":"10.1016\/j.jacc.2012.06.036","article-title":"10-Year Exercise Training in Chronic Heart Failure: A Randomized Controlled Trial","volume":"60","author":"Belardinelli","year":"2012","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1001\/jama.2020.26812","article-title":"Effect of High-Intensity Interval Training, Moderate Continuous Training, or Guideline-Based Physical Activity Advice on Peak Oxygen Consumption in Patients with Heart Failure with Preserved Ejection Fraction: A Randomized Clinical Trial","volume":"325","author":"Mueller","year":"2021","journal-title":"JAMA"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"833","DOI":"10.1177\/2047487316687428","article-title":"Effect of Functional Electrical Stimulation on Cardiovascular Outcomes in Patients with Chronic Heart Failure","volume":"24","author":"Kadoglou","year":"2017","journal-title":"Eur. J. Prev. Cardiol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"477","DOI":"10.1111\/j.1742-1241.2012.02900.x","article-title":"Diagnostic accuracy of exercise stress testing for coronary artery disease: A systematic review and meta-analysis of prospective studies","volume":"66","author":"Banerjee","year":"2012","journal-title":"Int. J. Clin. Pract."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"310","DOI":"10.1007\/BF03324707","article-title":"Effects of a one-year exercise training program in adults over 70 years old: A study with a control group","volume":"19","author":"Deley","year":"2007","journal-title":"Aging Clin. Exp. Res."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1016\/j.ehj.2003.09.027","article-title":"Beneficial Effects of Chronic Low-Frequency Stimulation of Thigh Muscles in Patients with Advanced Chronic Heart Failure","volume":"25","author":"Nuhr","year":"2004","journal-title":"Eur. Heart J."},{"key":"ref_39","first-page":"306","article-title":"Intra-Session Combination of Aerobic and Electromyostimulation Training in Chronic Heart Failure Patients","volume":"163","author":"Dobsak","year":"2012","journal-title":"Int. J. Cardiol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"254","DOI":"10.1097\/HJR.0b013e328339b5a2","article-title":"Functional Electrical Stimulation in the Treatment of Patients with Chronic Heart Failure: A Meta-Analysis of Randomized Controlled Trials","volume":"17","author":"Sbruzzi","year":"2010","journal-title":"Eur. J. Cardiovasc. Prev. Rehabil."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"e051073","DOI":"10.1136\/bmjopen-2021-051073","article-title":"Efficacy and safety of transcutaneous electrical nerve stimulation (TENS) for acute and chronic pain in adults: A systematic review and meta-analysis of 381 studies (the meta-TENS study)","volume":"12","author":"Johnson","year":"2022","journal-title":"BMJ Open"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"27","DOI":"10.1016\/S2213-2600(15)00503-2","article-title":"Neuromuscular Electrical Stimulation to Improve Exercise Capacity in Patients with Severe COPD: A Randomised Double-Blind, Placebo-Controlled Trial","volume":"4","author":"Maddocks","year":"2016","journal-title":"Lancet Respir. Med."},{"key":"ref_43","first-page":"295","article-title":"Exercise Training in Heart Failure: A Narrative Review","volume":"27","author":"Nascimento","year":"2014","journal-title":"Int. J. Cardiovasc. Sci."},{"key":"ref_44","first-page":"376","article-title":"Neuromuscular Electrical Stimulation in Patients with Advanced Heart Failure: A Case Series","volume":"57","author":"Miyamoto","year":"2016","journal-title":"Int. Heart J."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"19","DOI":"10.1016\/j.cmpb.2017.01.004","article-title":"Computer-Aided Decision Making for Heart Disease Detection Using Hybrid Neural Network\u2013Genetic Algorithm","volume":"141","author":"Arabasadi","year":"2017","journal-title":"Comput. Methods Programs Biomed."},{"key":"ref_46","first-page":"163","article-title":"Cardiac Resynchronization Therapy and Autonomic Nervous System: A Systematic Review","volume":"52","author":"Vaquero","year":"2018","journal-title":"J. Interv. Card. Electrophysiol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/10\/3826\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T14:35:22Z","timestamp":1778855722000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/10\/3826"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,15]]},"references-count":46,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,5]]}},"alternative-id":["jcm15103826"],"URL":"https:\/\/doi.org\/10.3390\/jcm15103826","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,15]]}}}