OBJECTIVE Despite strong evidence, access to exercise-based cardiac rehabilitation (ExCR) remains low across global healthcare systems. We provide a contemporary update of the Cochrane review randomized trial evidence for ExCR for adults with heart failure (HF) and compare different delivery modes: centre-based, home-based (including digital support), and both (hybrid). RESULTS Databases, bibliographies of previous systematic reviews and included trials, and trials registers were searched with no language restrictions. Randomized controlled trials, recruiting adults with HF, assigned to either ExCR or a no-exercise control group, with follow-up of ≥6 months were included. Two review authors independently screened titles for inclusion, extracted trial and patient characteristics, outcome data, and assessed risk of bias. Outcomes of mortality, hospitalization, and health-related quality of life (HRQoL) were pooled across trials using meta-analysis at short-term (≤12 months) and long-term follow-up (>12 months) and stratified by delivery mode. Sixty trials (8728 participants) were included. In the short term, compared to control, ExCR did not impact all-cause mortality (relative risk [RR] 0.93; 95% confidence interval [CI] 0.71-1.21), reduced all-cause hospitalization (RR 0.69; 95% CI 0.56-0.86, number needed to treat: 13, 95% CI 9-22), and was associated with a clinically important improvement in HRQoL measured by the Minnesota Living with Heart Failure Questionnaire (MLWHF) overall score (mean difference: -7.39; 95% CI -10.30 to -4.47). Improvements in outcomes with ExCR was seen across centre, home (including digitally supported), and hybrid settings. A similar pattern of results was seen in the long term (mortality: RR 0.87, 95% CI 0.72-1.04; all-cause hospitalization: RR 0.84, 95% CI 0.70-1.01, MLWHF: -9.59, 95% CI -17.48 to -1.50). CONCLUSIONS To improve global suboptimal levels of uptake for HF patients, global healthcare systems need to routinely recommend ExCR and offer a choice of mode of delivery, dependent on an individual patient's level of risk and complexity.