AIMS: Exercise training improves aerobic capacity (VO2peak) in patients with heart failure and preserved ejection fraction (HFpEF), but underlying mechanisms remain unclear. We aimed to evaluate whether exercise training could improve systolic and diastolic function during exercise. METHODS: This was a substudy of the multicentre Optimizing Exercise Training in HFpEF (OptimEx-Clin) trial, in which 180 patients with HFpEF were randomized 1:1:1 to guideline control, moderate continuous training or high-intensity interval training. All patients included at two out of five participating sites underwent exercise echocardiography at baseline and 3 months. Patients of both training groups were pooled and compared with guideline control. RESULTS: A total of 61 patients (mean age 73 +/- 7 years, 72% female) were included. At baseline, E/e' increased from 17.0 +/- 5.7 to 19.5 +/- 6.1 and systolic pulmonary artery pressure from 31 +/- 8 to 51 +/- 11 mmHg (both p < 0.001). Right ventricular function did not change significantly (maximal tricuspid annular plane systolic excursion 24.7 +/- 4.0 mm, p = 0.051 versus baseline). At 3 months, patients randomized to exercise training improved VO2peak (control +0.2, training +2.7 mL/kg/min, p = 0.006) and demonstrated small but significant improvements in exercise E/e' (control 21.7 +/- 7.5 to 22.8 +/- 9.2, training 18.3 +/- 5.0 to 17.2 +/- 4.1, p = 0.044). No significant changes were observed in ejection fraction, mitral or tricuspid annular plane systolic excursion, S', A' or systolic pulmonary artery pressure (p > 0.05). Changes in E/e' were not associated with the change in VO2peak. CONCLUSIONS: In patients with HFpEF, exercise echocardiography revealed increases in filling pressures as well as a failure to augment right ventricular function during exercise. After 3 months of exercise training, HFpEF patients demonstrated a small improvement in diastolic function (exercise E/e'), but this did not explain the improved aerobic capacity.

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