Background <p>Exercise is recommended for cardiovascular prevention, but the comparative effects of different exercise modalities and weekly doses on carotid-femoral pulse wave velocity (cfPWV) in heterogeneous risk-enriched adults with cardiovascular risk-related conditions or characteristics remain uncertain. This systematic review and dose-response network meta-analysis aimed to compare exercise modalities for improving cfPWV and to explore model-derived dose-response patterns and approximate favorable dose regions.</p> Methods <p>PubMed, Cochrane Library, Web of Science, Embase, SPORTDiscus, and CINAHL were searched from inception to 22 February 2026 for English-language parallel-group randomized controlled trials reporting cfPWV in heterogeneous risk-enriched adults with cardiovascular risk-related conditions or characteristics. Pairwise meta-analysis, frequentist network meta-analysis, and Bayesian dose-response network meta-analysis were performed.</p> Results <p>Thirty-seven studies involving 2,110 participants were included. In direct pairwise analysis, exercise was associated with a reduction in cfPWV compared with control (WMD = -0.65, 95% CI -1.13 to -0.18), but heterogeneity was considerable (I² = 94.4%). Aerobic training and whole-body vibration training showed significant reductions versus control in modality-specific direct comparisons, whereas resistance training, combined training, interval training, and isometric handgrip training did not reach statistical significance. In the network meta-analysis, aerobic training (WMD = -0.65, 95% CI -1.08 to -0.22) and interval training (WMD = -1.07, 95% CI -1.66 to -0.49) were associated with lower cfPWV than control. The dose-response model suggested a nonlinear association, with the lower model-derived crossing region around 200–300 MET·min/week and the lowest fitted estimate around 700–800 MET·min/week at the overall exercise level. However, these values are approximate model-derived ranges, not exact clinical thresholds, and should be interpreted cautiously because of clinical heterogeneity, sparse evidence in some dose regions and exercise nodes, and uncertainty around threshold estimates.</p> Conclusions <p>Exercise may reduce cfPWV in heterogeneous risk-enriched adults with cardiovascular risk-related conditions or characteristics, particularly through aerobic and interval-based training in the network synthesis. Direct pairwise evidence supported exercise overall, aerobic training, and whole-body vibration training, but the certainty of evidence was generally low or very low and heterogeneity was considerable. The dose-response findings suggest a potential moderate-dose region with lower model-predicted cfPWV estimates at the overall exercise level, but these estimates should be considered model-derived and hypothesis-generating rather than definitive clinical prescription thresholds. These findings should be interpreted as average effects across diverse populations and exercise prescriptions rather than as uniform expected effects.</p> Trial registration <p>PROSPERO CRD420261372601.</p>