Exercise intolerance is a principal feature of heart failure with preserved ejection fraction (HFpEF), whether or not there is evidence of congestion at rest. The degree of functional limitation observed in HFpEF is comparable to patients with advanced heart failure and reduced ejection fraction. Exercise intolerance in HFpEF is characterized by impairments in the physiological reserve capacity of multiple organ systems, but the relative cardiac and extracardiac deficits vary among individuals. Detailed measurements made during exercise are necessary to identify and rank-order the multiorgan system limitations in reserve capacity that culminate in exertional intolerance in a given person. We use a case-based approach to comprehensively review mechanisms of exercise intolerance and optimal approaches to evaluate exercise capacity in HFpEF. We also summarize recent and ongoing trials of novel devices, drugs, and behavioral interventions that aim to improve specific exercise measures such as peak oxygen uptake, 6-min walk distance, heart rate, and hemodynamic profiles in HFpEF. Evaluation during the clinically relevant physiological perturbation of exercise holds promise to improve the precision with which HFpEF is defined and therapeutically targeted.

运动不耐受是射血分数保留性心力衰竭 (HFpEF) 的主要特征，无论静息时是否有充血证据。HFpEF 中观察到的功能限制程度与晚期心力衰竭和射血分数降低的患者相当。HFpEF 运动不耐受的特点是多个器官系统的生理储备能力受损，但相对的心脏和心外功能缺陷因人而异。运动期间进行的详细测量对于识别和排序多器官系统储备能力的限制是必要的，这些限制最终导致特定人的运动不耐受。我们使用基于案例的方法来全面审查运动不耐受的机制以及评估 HFpEF 运动能力的最佳方法。我们还总结了最近和正在进行的新型设备、药物和行为干预试验，旨在改善 HFpEF 中的特定运动指标，例如峰值摄氧量、6 分钟步行距离、心率和血流动力学特征。在临床相关的运动生理扰动期间进行评估有望提高 HFpEF 定义和治疗目标的精确度。