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Background Adaptive digital therapy enhances cognitive training efficacy compared with traditional methods but evidence in patients with coronary heart disease (CHD) and mild cognitive impairment (MCI) is lacking.Methods This randomised active-control trial compared multidomain adaptive (intervention) versus traditional non-adaptive (positive control) computerised cognitive training (CCT) in patients with CHD and MCI. Training lasted 30 min/session, five sessions/week, for 12 weeks (both groups) or 24 weeks (intervention only). The primary outcome was the proportion with improved overall cognitive function (Basic Cognitive Ability Test (BCAT)) at 12 weeks. Secondary outcomes included changes in overall/individual cognitive domains at 12/24 weeks improvements in patients’ various quality of life scales. Exploratory outcomes included training compliance and brain structural changes. An intention-to-treat analysis was performed on all randomised participants. Missing data were managed using multiple imputation.Results 224 patients from eight Chinese medical centres were randomised into a 1:1 ratio to adaptive CCT (n=112) or traditional CCT (n=112). There was no significant difference in the proportion of BCAT improvement between the two groups (p=0.947, OR=1.02, 95% CI 0.51 to 2.05). Both groups showed improved cognitive abilities at 12 weeks versus baseline (p=0.015 and p=0.016). Adaptive CCT also improved health-related quality of life (EuroQol-5 Dimensions Questionnaire-3-Level) at 12 weeks compared with traditional CCT, and both interventions showed positive trends in improving anxiety and depression symptoms. The adaptive group had better compliance (p=0.009) and significantly increased grey-matter volume in the left supplementary motor area, right precuneus and right superior parietal lobule (P family-wise error=0.004).Conclusions The efficacy of multidomain adaptive CCT in this population is not superior to that of traditional CCT. Although adaptive CCT has a higher compliance rate and can bring more significant changes in brain structure.Trial registration number NCT05735041.