Exercise Training for Patients with Heart Failure with Preserved Ejection Fraction: A Systematic Review and Bayesian...

To compare exercise training modalities in heart failure with preserved ejection fraction (HFpEF) and rank them for exercise capacity, cardiac function and quality of life (QoL).

PubMed, Embase, Web of Science and the Cochrane Library were searched to 31 December 2025 for randomized controlled trials (RCTs) of exercise in adults with HFpEF (ejection fraction ≥50%). Bayesian random-effects network meta-analysis estimated standardized mean differences (SMDs, 95% credible intervals [CrIs]) across eight nodes. Twenty reports of 15 RCTs (1,554 randomized; 1,161 after deduplication) were included; mean age was 69.0 ± 8.0 years, 63.0% were women, and 70% of trials enrolled New York Heart Association class II-III. Session completion was 76-90% in ≤12-week trials and 38.1% at 12 months. Combined aerobic and resistance training (CART; SMD 0.58, 0.31-0.86; p = 0.002), high-intensity interval training (HIIT; 0.56, 0.07-1.09; p = 0.026) and moderate continuous training (MCT; 0.46, 0.23-0.70; p = 0.001) improved peak oxygen consumption (peak VO2), gains of 2.61, 2.52 and 2.07 mL·kg-1·min-1, above the ∼1.0 minimal clinically important difference. For QoL, functional electrical stimulation (FES) was the only node with a CrI excluding zero (0.86, 0.25-1.48; 2 trials, n = 30). FES ranked first for the early/late mitral inflow (E/A) ratio, with CrI including zero (0.68, -0.05-1.41). No node affected left ventricular ejection fraction, B-type natriuretic peptide or left atrial volume index. Heterogeneity was substantial for peak VO2 (I2 = 65.8%; Egger's p = 0.017) and ≤6.9% elsewhere.

CART, HIIT and MCT carry the clearest evidence of improved exercise capacity in HFpEF. FES is a candidate where QoL is the priority. Several nodes rest on single small trials.