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Background Depression is common after cardiovascular events, including myocardial infarction, coronary artery bypass grafting or acute heart-failure exacerbation, and independently predicts poorer outcomes from cardiac rehabilitation (CR). CR is a structured, multidisciplinary programme of supervised exercise, education and psychosocial support to promote recovery and reduce recurrence. Although psychological support is advocated in CR, the additional value of structured Cognitive Behavioural Therapy (CBT) beyond routine CR counselling remains unclear.Aim To systematically review whether integrating structured CBT into CR improves depressive symptoms and health-related quality of life (HRQoL) in adults with cardiovascular disease versus CR alone.Methods A systematic search of MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane CENTRAL was conducted. Randomised controlled trials comparing CR plus CBT with CR alone without structured CBT were eligible. Adults with cardiovascular disease and baseline depression were included; anxiety-only trials or those without a CR component were excluded. PRISMA and JBI methods guided screening, quality appraisal. Due to clinical heterogeneity, results were narratively synthesised.Results The search identified 1,537 records; six RCTs, including one follow-up (totalling 633 participants), met the criteria. Face-to-face CBT delivered alongside exercise-based CR resulted in greater reductions in depression scores (1.3–3.9 points on HADS-D/T within 6–12 weeks) and clinically meaningful improvements in HRQoL, with high adherence rates (77–92%). In contrast, the single digital CBT trial showed no significant benefit over usual care (HADS-D: β = -0.47, p = 0.53), a result likely influenced by low participant engagement (15% completed >1 module). A key moderating factor was baseline depression, with patients experiencing moderate-to-severe symptoms showing the greatest treatment response.Conclusion Structured, face-to-face CBT integrated into CR effectively reduces depression and improves HRQoL. The findings strongly support policies for routine depression screening at CR entry to enable targeted CBT allocation, thereby optimising recovery for patients with higher symptom severity.