Studies selection

We initially identified 1884 studies, from which 1257 were excluded as duplicates. We screened the remaining 609 studies by titles and abstracts, and 120 full-text articles were retrieved to identify eligibility. Four studies were not retrieved, and 78 studies were excluded for specific reasons. Finally, a total of 37 studies (38 reports) met the inclusion criteria [35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72]. The selection procedure is shown in a PRISMA Flow Diagram (Fig. 1).

Fig. 1
figure1

PRISMA Flow Diagram. Note: PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement, which is used worldwide to improve the reporting of systematic reviews and meta-analyses

Studies characteristics

Of the included reports, 16 were published in English and 22 in the Chinese language between 2004 and 2021. These studies were conducted in China, the United Kingdom, the United States, Italy, South Korea, and Australia. There were 12 studies that enrolled people with chronic heart failure [35, 36, 38, 45, 49,50,51, 62, 64,65,66,67, 72], nine studies with type 2 diabetes [41, 48, 52, 57,58,59, 63, 68, 69], eight studies with coronary heart diseases [39, 40, 43, 44, 47, 61, 70, 71], seven studies with hypertension [37, 42, 46, 53, 55, 56, 60], and one study with stroke [54]. The sample size of the included studies ranged from 16 to 326, with an average of 95, totalling 3525 participants. Table 1 shows the characteristics of the included studies.

Table 1 Characteristics of included studies on Tai Chi for CVD and/or risk factors

Various Tai Chi styles and forms, time per session, frequencies, and durations were utilised. The majority of studies applied the Yang style, and the most popular one was the 24-form Simplified Yang style. Most studies practiced a modified/simplified version of Tai Chi in group classes, under the supervision and instruction of a professional Tai Chi instructor, an experienced trainer, or exercise physiologist. Home practice, in addition to group classes, was encouraged or required in nine studies [35, 37, 38, 50, 54, 56, 65,66,67]. The frequency and duration varied from 5 to 120 min (standardised or increased gradually) per session, 2 to 14 sessions per week, lasting 8 to 240 weeks. Table S2 lists the details of the Tai Chi interventions used in the included studies.

Methodological quality

We contacted the corresponding authors by email to clarify unclear or missing information in the papers; however, the response rate was low. Accordingly, only three studies were rated as low risk of bias in all six items, and the majority were rated as unclear risk of bias. The overall methodological quality of the included studies was poor (Fig. S1 and S2).

Although all included studies mentioned ‘randomised’, only 21 studies (21/37, 56.8%) reported the methods for sequence generation, including ‘random number table’ and ‘computer-generated allocation method’. Seven studies (7/37, 18.9%) reported information on allocation concealment, eight studies (8/37, 21.6%) reported the blinding of outcome assessors, 21 studies (21/37, 55.6%) reported information about participants lost to follow up, and 10 studies (10/37, 27.0%) reported their protocol registration.

Effects of interventions

The effect estimates of Tai Chi for psychological well-being and QoL in people with or at risk of CVD and the post-hoc subgroup analyses were shown in Table S3 and Table S4, respectively. Tables 2 and 3 respectively present the summary of main findings when Tai Chi plus usual care was compared with usual care alone and Tai Chi was compared with aerobic exercise. Table S5 presents the GRADE certainty assessment in detail.

Table 2 Summary of findings: Tai Chi plus usual care compared to usual care for psychological well-being and QoL in people with CVD and risk factors
Table 3 Summary of findings: Tai Chi compared to aerobic exercise for psychological well-being and QoL in people with CVD and risk factors

Stress

Narrative synthesis

Two studies [37, 44] reported the effects of Tai Chi on stress. We did not pool their data because of the different comparisons applied in their studies.

Liu et al. (2020) [44] compared Tai Chi combined with usual care and usual care alone in people with CHD, and measured stress with the Perceived Stress Scale 14-item (PSS-14) (Range from 0 to 56; a higher score indicates greater stress). A significantly greater stress reduction was found in the Tai Chi plus usual care group, compared with usual care alone (including usual pharmacologic therapy, examination, nursing, and health education) (Very low certainty) (Table 2, Table S5).

Chan et al. (2018) [37] compared Tai Chi with aerobic exercise alone or no treatment in people with hypertension, and measured stress with the Perceived Stress Scale 10-item (PSS-10) (Range from 0 to 40; higher scores reflect higher levels of perceived stress). This study showed that the Tai Chi group achieved a significantly greater reduction in stress than the control and aerobic exercise groups (Low certainty) (Table 3, Table S5).

Anxiety

Five studies [41, 43, 44, 55, 60] investigated the effects of Tai Chi on anxiety.

Meta-analysis

The meta-analysis indicated that Tai Chi in combination with usual care is superior in reducing anxiety (SMD -2.13, 95% CI: − 2.55, − 1.70, 3 studies, I2 = 60%) (Low certainty) to usual care alone (including pharmacologic therapy, advice on medication, daily life behaviour, psychological support, diet, and exercise), in people with CHD or hypertension (Table 2, Table S5). A subgroup analysis found similar results among people with CHD (SMD -1.98, 95% CI: − 2.65, − 1.31, 2 studies, I2 = 76%) (Table S4).

Narrative synthesis

Two studies [41, 55] reported anxiety as measured by Zung Self-Rating Anxiety Scale (SAS) (scale from 20 to 80; a lower score indicates less anxiety), and found that the Tai Chi group experienced a significantly greater reduction in anxiety than the usual pharmacological therapy intervention for people with T2DM [41], and health education in people with hypertension [55].

Depression

Eleven studies [41, 43,44,45,46, 50, 52, 55, 68, 69, 72] reported the effects of Tai Chi on depression.

Meta-analysis

Findings from the meta-analysis indicated that Tai Chi in combination with usual care significantly improved depression (SMD -0.86, 95% CI: − 1.35, − 0.37, 6 studies, I2 = 88%) (Low certainty), compared with usual care alone, in people with CHD, hypertension, or T2DM (Table 2, Table S5). Subgroup analyses for CHD, HF, and T2DM demonstrated consistent findings, but could not identify the source of the statistical heterogeneity in the meta-analysis (Table S4).

Another two meta-analyses found that Tai Chi was equally effective in reducing depression compared with that of aerobic exercise (SMD -0.10, 95% CI: − 0.62, 0.43, 2 studies, I2 = 0%) (Very low certainty) (Table 3, Table S5) or health education (SMD -0.11, 95% CI: − 0.78, 0.56, 2 studies, I2 = 76%) (Table S3).

Narrative synthesis

Gong et al. (2020) [41] reported Tai Chi was superior in reducing depression scores on the Zung Self-Rating Depression Scale (SDS) (scale from 20 to 80; a smaller score indicates less depression), relative to usual pharmacological therapy in people with T2DM.

Mood

Four studies [35, 58, 65, 67] reported the effects of Tai Chi on mood. We did not pool the data because of different comparisons and estimates (e.g., MD and median).

Narrative synthesis

Two studies [35, 58] assessed mood using the Symptom Checklist-90-Revised (SCL-90-R) by comparing Tai Chi in combination with usual care and usual care alone (including usual pharmacologic therapy, and health education). Barrow et al. (2007) [35] found no between-group differences in both SCL-90-R anxiety and depression scores in people with chronic heart failure, while Wang (2014) [58] found that Tai Chi plus usual care was superior to usual care alone in changing the SCL-90-R anxiety score in people with T2DM.

Another two studies [65, 67] measured changes in mood in respect to Tai Chi using the Profile of Mood States (POMS) scale in people with chronic heart failure. One study [65] involving 100 participants reported a significant improvement in median scores of total mood disturbance, depression, and vigour subscales of POMS in the Tai Chi group compared with the health education group, while the other study [67] involving 16 participants found no significant differences in POMS scores between the Tai Chi and aerobic exercise groups.

Self-efficacy

Narrative synthesis

Two studies [52, 67] reported the effects of Tai Chi on self-efficacy. The Tai Chi and usual care group experienced a greater increase of self-efficacy than that of the usual care group in people with T2DM. Tai Chi was found to be equally effective in increasing self-efficacy scores compared with aerobic exercise in people with chronic heart failure.

Quality of life

Thirty studies [35,36,37,38,39,40, 42,43,44,45,46,47,48,49, 51, 53, 54, 56, 57, 59,60,61,62,63,64,65,66,67, 70,71,72] reported the effects of Tai Chi on QoL.

Meta-analysis

Findings from the meta-analysis found that, compared with usual care alone, Tai Chi plus usual care significantly improved the total score of SF-36 (MD: 18.91, 95% CI: 12.80, 25.03, 3 studies, I2 = 54%) (Low certainty), mental health (MD: 7.86, 95% CI: 5.20, 10.52, 11 studies, I2 = 71%) (Low certainty), and bodily pain (MD: 6.76, 95% CI: 4.13, 9.39, 11 studies, I2 = 75%) (Low certainty) (Table 2, Table S5). The other domains of SF-36 all showed significant between-group differences in favour of the Tai Chi group, however, we did not use the pooled results due to considerable heterogeneity. Subgroup analyses could not explain all the heterogeneity, but found favourable effects of Tai Chi in improving: role limitation due to physical health for people with CVD risk factors (MD: 9.37, 95% CI: 6.33, 12.41, 6 studies, I2 = 15%); role limitation due to emotional health for people with CVD risk factors (MD: 8.04, 95% CI: 3.28, 12.81, 6 studies, I2 = 72%), and with CHD (MD: 16.09, 95% CI: 13.04, 19.14, 3 studies, I2 = 41%); energy/vitality in people with CVD risk factors (MD: 6.60, 95% CI: 3.23, 9.98, 6 studies, I2 = 57%); mental health in people with CVD risk factors (MD: 7.75, 95% CI: 3.77, 11.72, 6 studies, I2 = 69%), and with heart failure CVD risk factors (MD: 6.62, 95% CI: 1.04, 12.20, 2 studies, I2 = 55%); bodily pain in people with CVD risk factors (MD: 7.19, 95% CI: 3.23, 11.15, 6 studies, I2 = 59%), and with heart failure (MD: 5.92, 95% CI: 0.54, 11.30, 2 studies, I2 = 75%); and general health in people with CVD risk factors (MD: 9.95, 95% CI: 6.71, 13.18, 6 studies, I2 = 41%), and with heart failure (MD: 7.89, 95% CI: 2.72, 13.06, 2 studies, I2 = 70%) (Table S4).

Five studies [51, 64, 66, 71, 72] assessed QoL using the Minnesota Living with Heart Failure Questionnaire (MLHFQ), comparing Tai Chi in combination with usual care and the usual care alone in people with CHD and chronic heart failure. The pooled data found significantly favourable effects of Tai Chi; however, due to considerable heterogeneity which was not explained by subgroup analyses, we did not use the findings (Table S4). Another meta-analysis found that Tai Chi was equally effective in improving MLHFQ scores compared with that of aerobic exercise in people with chronic heart failure (MD: 1.55, 95% CI: − 8.50, 11.59, 2 studies, I2 = 0%) (Very low certainty) (Table 3, Table S5).

Narrative synthesis

The improvement of QoL measured by CQQC in the Tai Chi plus Chinese herbal medicine group was greater than that of the Chines herbal medicine alone group in people with CHD [70]. Similar findings were found in the Tai Chi combined with the usual care group, as measured by the abbreviated World Health Organization Quality of Life (WHOQOL-BREF) in people with hypertension [60]. Tai Chi had greater improvements in the mental component of SF-12 compared with the no treatment and aerobic exercise alone groups [37], and five domains of SF-36 compared with the aerobic exercise alone group [40]. When compared with non-exercise-based group activities, the Tai Chi group experienced greater improvement in six domains of SF-12, including role limitation due to physical health, role limitation due to emotional health, energy/vitality, mental health, social functioning, and bodily pain in people with hypertension [56]. Compared with usual care (i.e. usual stroke rehabilitation program including health education on stroke-specific symptom management via text messages), Song et al. (2021) [54] found that the Tai Chi group had greater increases in Stroke-Specific Quality of Life (SS-QOL) scores in the mood and thinking domains in people with stroke.

Safety/adverse events

Eleven studies (11/37, 29.7%) reported safety/adverse events information. These studies involved people with T2DM, hypertension, CHD, chronic heart failure, and stroke.

Meta-analysis

Findings of the meta-analysis suggested that Tai Chi combined with usual care did not increase the risk of adverse events (RR: 0.50, 95% CI: 0.21, 1.20, 5 studies, I2 = 0%) (Very low certainty), compared with usual care alone (Table 2, Fig. S3). Subgroup analyses found consistent results (Table S4).

Narrative synthesis

No adverse events were reported to occur during Tai Chi sessions in eight studies. Three studies, involving people with CHD [47], stroke [54] and heart failure [67], reported no adverse events during their study periods, while other studies reported various adverse events in Tai Chi and control groups, including deaths (n = 9) [35, 42, 50, 65], heart failure decompensation (n = 1) [50], sepsis (n = 1) [50], fatigue (n = 3) [38, 50, 57], hospitalizations due to heart failure exacerbation, angina or shortness of breath (n = 11) [65, 66], arrhythmias (n = 2) [65], syncope (n = 2) [65], falls (n = 3) [65], dizziness [38], minor muscular soreness (n = 3) [38], worsening heart failure (n = 3) [35, 36] and worsening co-morbidities (n = 2) [35]. The authors concluded that these adverse events were unlikely to be caused by the Tai Chi interventions.

Tai Chi did not increase adverse events when compared with aerobic exercise [38], health education [65], or non-exercise-based group activities [57] (Table S3).

Publication Bias

The funnel plot did not detect a publication bias in studies on Tai Chi for QoL in people with CVD or risk factors (Fig. S4).

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