Heart failure with preserved ejection fraction (HFpEF) is a complex syndrome with increasing incidence and poor prognosis, accounting for up to 50% of heart failure cases. It is strongly associated with aging, cardiovascular risk factors (hypertension, diabetes, obesity), and is more prevalent in women than men. Patients with HFpEF frequently present with dyspnea, debilitating fatigue, poor quality of life, frequent hospitalizations, and high mortality rates. This study aims to evaluate the effects of a structured exercise program on cardiac function, skeletal muscle metabolism, functional capacity, and quality of life in patients with HFpEF, and to explore whether these benefits are mediated by circulating exerkines.
Standard pharmacological treatments have shown limited prognostic benefit, highlighting the need for non-pharmacological strategies. Exercise training may represent an effective therapeutic tool, with potential to improve cardiac remodeling, skeletal muscle bioenergetics, exercise tolerance, and quality of life. Importantly, exerkines-molecules secreted by skeletal muscle and other organs in response to exercise-may mediate systemic beneficial effects by modulating metabolic, immuno-inflammatory, and growth pathways.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
BASIC_SCIENCE
Masking
DOUBLE
Enrollment
150
Supervised training
Universidad Pública de Navarra (UPNA)
Pamplona, Navarre, Spain
Peak oxygen consumption
Changes in peak oxygen consumption between and within groups at 12-week Unit of measure of peak oxygen consumption: mL/kg/min. Maximal functional capacity will be evaluated using incremental and symptom-limited cardiopulmonary exercise testing on a bicycle ergometer, beginning with a workload of 25 W and increasing gradually in a ramp protocol at 25-W increments every 3 minute. We define maximal functional capacity as when the patient stops pedalling because of symptoms and the respiratory exchange ratio (RER) was \>1. Gas exchange data and cardiopulmonary variables were averages of values taken every 10 seconds. Peak oxygen consumption (PeakVO2) was defined as the highest value of VO2 during the last 20 seconds of exercise.
Time frame: Baseline and 12-week
Lean mass (kg)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Changes in blood pressure
Systolic and diastolic blood pressure of participants in fasting condition will be analyzed by electronic tensiometer and reported in mmHg.
Time frame: Baseline and 12-week
Changes in Heart rate
Heart rate of participants in fasting condition will be analyzed by electronic tensiometer and reported in pulses/min.
Time frame: Baseline and 12-week
Changes in muscle strength
Grip strength of participants will be measured using a manual dynamometer and reported in kg. Pectoral press, bilateral leg-press, knee extension, and back press) will be measured using a eGYM machines and reported in kg
Time frame: Baseline and 12-week
Changes in quality of life
We will use the EuroQol five-dimension five-level questionnaire (EQ-5D-5L) to assess health-related quality of life. The EQ-5D-5L includes five domains (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression), each rated on a 5-point scale ranging from 1 (no problems) to 5 (extreme problems). The responses are combined into an index value ranging from -0.594 to 1, where higher scores indicate a better health-related quality of life.
Time frame: Baseline and 12-week
Physical activity and sedentary behaviour (in minutes)
Physical activity level objectively measured using Actigraph Accelerometry. This will be worn on the waist and will passively record physical activity and sedentary behavior.
Time frame: Baseline and 12-week
Pittsburgh Sleep Quality Index
A 19-item self-report questionnaire that assesses subjective sleep quality and disturbances over the past month will be evaluated by Pittsburgh Sleep Quality Index. The global score ranges from 0 to 21, with higher scores indicating poorer sleep quality.
Time frame: Baseline and 12-week
Epidemiological Studies-Depression Scale questionnaire
Depression levels will be assessed using the Center for Epidemiological Studies-Depression Scale (CES-D) questionnaire, which is validated and widely employed in cardiometabolic patients. The CES-D consists of 20 items, each rated on a 4-point Likert scale ranging from 0 (rarely or none of the time) to 3 (most or all of the time), assessing the frequency of depressive symptoms during the past week. The total score ranges from 0 to 60, with higher scores indicating greater depressive symptomatology.
Time frame: Baseline and 12-week
Cognitive Function
Global cognitive function will be assessed using the Montreal Cognitive Assessment (MoCA), a validated screening tool that evaluates multiple cognitive domains, including executive function, memory, attention, language, and visuospatial abilities. The total score ranges from 0 to 30, with higher scores indicating better cognitive performance.
Time frame: Baseline and 12-week
Adherence to the Mediterranean Diet
Adherence to the Mediterranean dietary pattern will be assessed using the Mediterranean Diet Adherence Screener (MEDAS), a validated 14-item questionnaire designed to evaluate compliance with key components of the Mediterranean diet. Each item is scored 0 or 1, depending on whether the dietary criterion is met, yielding a total score ranging from 0 to 14, where higher scores indicate greater adherence to the Mediterranean diet.
Time frame: Baseline and 12-week
Psychological Distress
The Kessler Psychological Distress Scale (K10) will be used to assess nonspecific psychological distress, including symptoms of anxiety and depression, experienced over the past four weeks. The K10 consists of 10 items, each rated on a 5-point Likert scale ranging from 1 (none of the time) to 5 (all of the time), resulting in a total score between 10 and 50. Higher scores indicate greater psychological distress.
Time frame: Baseline and 12-week
Haematology
Erythrocyte count (×10⁶ cells/µL), haematocrit (%), haemoglobin (g/dL), platelet count (×10³ cells/µL), leukocyte count (×10³ cells/µL), and erythrocyte mean corpuscular volume (fL) will be quantified using a Coulter haematology analyzer (Brand, City, Country).
Time frame: Baseline and 12-week
Concentrations of circulating cytokines, adipokines, myokines, and bone metabolism biomarkers.
Plasma concentrations of pro-inflammatory and anti-inflammatory cytokines (IL-1β, IL-2, IL-6, IL-8, IL-10, IFN-γ, TNF-α, IL-1ra, and TNF sRII-α), adipokines (adiponectin, adipsin, resistin, PAI-1 active, insulin, and leptin), and myokines (irisin) will be quantified using Luminex xMAP technology. In addition, biomarkers related to bone metabolism (ACTH, DKK-1, FGF-23, osteocalcin, osteopontin \[OPN\], osteoprotegerin, PTH, and sclerostin \[SOST\]) will be measured with the same platform. Each analyte will be reported separately as an independent outcome, with concentrations expressed in pg/mL or ng/mL, as appropriate for the specific biomarker.
Time frame: Baseline and 12-week
Resting energy expenditure
Resting energy expenditure is measured in the fasting and fed state by indirect calorimetry
Time frame: Baseline and 12-week
N-terminal pro-B-type natriuretic peptide (NT-proBNP)
N-terminal pro-B-type natriuretic peptide (NT-proBNP) will be quantified by standardized immunoassay (e.g., electrochemiluminescence immunoassay, ECLIA) following manufacturer's instructions
Time frame: Baseline and 12-week
Lean mass index (kg/m2)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Appendicular lean mass index (kg/m2)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Fat mass index (kg/m2)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Fat mass (kg)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Visceral adipose tissue (kg)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Lean mass/fat mass ratio
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Fat free mass
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
Whole bone mineral density (g/cm2)
Dual-energy X-ray absorptiometry (DXA) body composition measure
Time frame: Baseline and 12-week
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