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

AIMS: 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). METHODS AND RESULTS: 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. CONCLUSIONS: 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.