Teaching and learning technologies are increasingly sought after and promoted in higher education. Among the innovative options is simulation.¹ Simulation provides students with the opportunity to engage in complex clinical scenarios in a safe and controlled setting. Additionally, it facilitates the development of technical and communication skills, as well as the practice of clinical decision-making and teamwork.^1,2 By offering a realistic learning environment, simulation complements traditional clinical practice and enhances the training of future doctors.³

Through simulation, students can acquire and improve technical skills, such as clinical procedures, handling medical equipment, and surgical skills.^4,5 In addition, they have the opportunity to practice effective communication with patients and their families, developing essential skills for medical practice.⁶ Some studies indicate that, within cardiology, the use of simulation increases student adherence and satisfaction, which are key indicators of engagement and acceptance of educational methods in this field. This evidence can lead to improvements in students’ skills and competence, both in undergraduate and postgraduate courses.^7,8

By practicing procedures and making clinical decisions in a simulated environment, students can make mistakes and learn from them without putting patients at risk.⁹ In addition to the educational advantages, simulation also offers benefits for patient safety. Despite these advantages, the use of simulation requires qualified instructors and time for planning and conducting the sessions, which can be an obstacle.^10,11 However, these challenges can be overcome with proper planning and investment in infrastructure.¹² In cardiology, for example, there are specific simulators for cardiac auscultation, coronary anatomy, and performing invasive procedures. Therefore, the aim of this study was to evaluate the available evidence on the use of simulation in medical education in comparison to traditional teaching methods, specifically within the context of cardiology education.

Figure 1 shows the PRISMA flowchart of the search and selection process. A total of 435 studies were identified through the database search. After removing duplicates, the abstracts of 412 studies were assessed and included if deemed appropriate. The full text of 40 articles was evaluated for eligibility, and 7 articles were ultimately included for qualitative synthesis.

The assessment of the risk of bias is presented in Figures 2 and 3, where detailed analyses have been conducted. These figures clearly illustrate the criteria used to determine the reliability of the data and the quality of the included studies, allowing for a deeper understanding of the potential impacts on the final results (Figures 2 and 3).

Table 1 provides a summary of the 7 studies ultimately included, which involved 823 medical students from their third to final year. The studies were conducted in 4 different countries, with the number of participants per study varying from 18 to 219.

The studies included in this review found an improvement in the ability to auscultate the heart, to recognize coronary anatomy, and to perform catheterization and angioplasty. In addition, there was also an increase in student adherence and satisfaction (Central Illustration).

Performing auscultation in the traditional way can reduce students’ ability to recognize alterations. In general, one student tends to auscultate the other; as there are no alterations, the student ends up recognizing the normal sound, and it is not possible to distinguish the type of impairment when examining patients. Authors such as Bernardi et al.,¹⁵ Kern et al.,¹⁹ and Rüllmann et al.²¹ have shown that the use of simulation increased the ability to recognize sounds at the end of the training period. A meta-analysis published by McKinney et al.²² concluded that simulation-based learning is an effective educational strategy for teaching cardiac auscultation.

Similar results have been seen in the teaching of medicine as well as nursing.²³ These results reinforce the fact that simulation-based learning is capable of increasing competences and skills and is not associated with a specific course. The playfulness and closeness to reality favor the teaching-learning process, creating a favorable environment conducive to teaching.

The study by Lee et al.¹⁶ highlights the importance of innovative teaching methods, such as simulation-based learning, in coronary anatomy education. This approach is consistent with previous research highlighting the benefits of simulation in medical education. For example, in a study conducted by Johnson et al.,²⁴ the authors demonstrated that simulation increased student engagement and improved retention of anatomical knowledge compared to traditional teaching methods.

In addition, the study by Lee et al.¹⁶ highlights the importance of a practical and contextualized approach to teaching coronary anatomy. Authors such as Smith et al.²⁵ emphasize the need for students to understand the clinical relevance of anatomy to medical practice. Simulation offers students the opportunity to apply their anatomical knowledge in simulated clinical scenarios, better preparing them for clinical practice.

Another relevant point is simulation's ability to provide a safe environment for practice and error. Authors such as Estai et al.²⁶ have shown that simulation allows students to experience different clinical scenarios and develop practical skills without the risk of harming real patients. This promotes more active and exploratory learning, contributing to a better understanding of coronary anatomy and its clinical application.

The use of simulation-based learning has proven effective in optimizing the angioplasty procedure. In the present study, participants reported increased confidence in performing technical procedures and greater ability to identify signs and symptoms of acute myocardial infarction after the simulation sessions. These findings are consistent with previous studies, such as those by Islam et al.²⁷ and Khokhar et al.,²⁸ which highlight that simulation provides a safe and controlled environment for practicing technical skills and complex procedures, such as coronary angioplasty. Similarly, Rourke et al.²⁹ demonstrated that simulation-based learning was effective in improving the recognition and management of acute myocardial infarction, especially by offering opportunities for practice in realistic contexts with immediate feedback. In addition, research such as that by Farina et al.³⁰ has shown that simulation provides a realistic opportunity for learners to apply theoretical knowledge in practice, enabling a better understanding of the pathophysiology of acute myocardial infarction and improving their decision-making skills in cardiovascular emergency situations.

The use of simulation not only generates technical improvements during learning; it also makes students want to use the material provided and increases their engagement during classes. Several studies included in this review found improved student satisfaction and adherence. This result corroborates the research by Kagaya et al.³¹ and Birdane et al.³² In both studies, the level of satisfaction was higher in the group that used realistic simulation. Traditional teaching is being widely criticized.³³ Students in a more technological age prefer activities that involve skills that will be put into practice in the real world.

Students who demonstrate higher levels of engagement tend to be more participative and are better equipped to develop the competencies and skills expected of them.^34,35 Additionally, incorporating "real-world" elements into scenario construction enhances the validity of the simulation. For example, Zhang et al.³⁶ simulated cardiac emergencies using real patients recovering from a previous cardiac event, integrating intermittent interruptions to mimic a real-life "on-call scenario." This approach reflects the multitasking, time management, and composure required of doctors who often need to manage multiple tasks under pressure.

The correlation of the observed outcomes in the included studies reveals a significant diversity in methodological approaches, reflecting different contexts and target populations. This heterogeneity in simulation and evaluation methods is crucial for the interpretation of the results, since variations in experimental protocols can directly influence the observed outcomes. For example, some studies adopted simulations based on computational models, whereas others used controlled clinical experiments. These discrepancies not only make direct comparison of results difficult, but also highlight the inherent limitations in generalizing the findings. Therefore, it is essential to recognize that differences in the methods used can contribute to variability in results, which should be carefully considered when discussing the implications and conclusions of the analyzed studies.

This review has some limitations, such as the heterogeneity of simulation and evaluation methods. This limitation made it impossible to carry out a more robust analysis or meta-analysis.

This systematic review provides robust evidence that simulation is an effective method for teaching cardiology to medical students, yielding significant positive outcomes compared to other teaching approaches, even with relatively short simulation sessions.