Comparative effectiveness of various exercise modalities on arterial stiffness and endothelial function in older adults: a systematic review and network meta-analysis of randomised controlled trials

Objective: We aimed to evaluate the comparative modulatory efficacy of various exercise modalities on endothelial function and arterial stiffness in older adults via a systematic review and network meta-analysis. Methods: We systematically searched eight electronic databases to identify randomised controlled trials (RCTs) evaluating seven distinct exercise modalities (aerobic, walking, resistance, combined, mind-body, stretching, and whole-body vibration training) in older adults aged 60 years or older. Eligibility criteria stipulated supervised, standardised training programmes with a minimum duration of 4 weeks and continuous monitoring of exercise intensity. To comprehensively evaluate the comparative efficacy of these modalities on arterial stiffness and endothelial function, a frequentist network meta-analysis was performed to mathematically integrate direct and indirect trial evidence. The certainty and quality of evidence were rigorously assessed via the Cochrane RoB 2.0 and CINeMA frameworks. Results: In primary analyses, whole-body vibration and resistance training ranked highest for enhancing endothelial function (FMD), whereas aerobic training and walking were associated with greater improvements in attenuating arterial stiffness (baPWV); However, extensive confidence interval overlap precluded definitive claims of clinical superiority. Regarding secondary outcomes, stretching exercise showed a higher probability of reducing systolic blood pressure (SBP) based on mean ranking estimates, while combined training ranked among the leading modalities for lowering diastolic blood pressure (DBP), though these findings warrant cautious interpretation as head-to-head differences generally lacked statistical significance. The observed reductions in blood pressure, particularly systolic decreases exceeding 10 mmHg, carry substantial clinical relevance, given that a reduction of this magnitude is typically associated with an approximate 20% down-risk in major adverse cardiovascular events within older populations. According to the CINeMA framework, the certainty of evidence was graded as moderate-to-high for FMD outcomes, but low-to-moderate for arterial stiffness comparisons. Conclusion: Accumulating evidence suggests that exercise-induced vascular adaptations in older adults are likely modality-specific. Whole-body vibration and resistance training appear to confer substantial optimisation upon endothelial function, whereas aerobic training and walking demonstrate potential advantages in attenuating arterial stiffness. Rather than supporting an immediate paradigm shift, these findings suggest that integrating exercise monitoring tailored to specific phenotypic characteristics may refine clinical prescriptions, though such implementation should be interpreted with caution given inherent study heterogeneity, reliance on indirect network comparisons, and potential risks of bias. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251236872, identifier CRD420251236872.