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Abstract   Aims  Visceral adipose tissue (AT) promotes inflammation and may be associated with disease progression in heart failure with preserved ejection fraction (HFpEF). We characterized regional AT distribution in HFpEF patients and controls and analysed associations with co‐morbidities and exercise tolerance.    Methods and results  Magnetic resonance imaging was performed to quantify epicardial, liver, abdominal, and thigh skeletal muscle AT. We assessed New York Heart Association (NYHA) class, 6 min walk distance, and global well‐being score. Multivariable linear regression models adjusting for body surface area were used. We studied 55 HFpEF patients (41 women, mean age 67 ± 11 years) and 33 controls (21 women, mean age 57 ± 10 years). Epicardial AT (median [interquartile range] 4.6 [2.0] vs. 3.2 [1.4] mm,  P  &lt; 0.001), thigh intermuscular fat (11.0 [11.5] vs. 5.0 [2.7] cm 2 ,  P  &lt; 0.001) and liver fat fraction (6.4% [6.1] vs. 4.1% [5.5],  P  = 0.001) were higher in HFpEF patients than controls. Women with HFpEF had higher abdominal and thigh subcutaneous AT than men. Greater thigh intermuscular fat was associated with higher blood pressure (β [SE] 0.73 [0.17],  P  &lt; 0.001) and diabetes (odds ratio [95% confidence interval] 1.2 [1.0–1.5],  P  = 0.03). Greater thigh intramuscular fat was associated with both worse NYHA class (β [SE] 2.7 [1.0],  P  = 0.01) and shorter 6 min walk distance (β [SE] −4.1 [1.9],  P  = 0.03), and greater epicardial AT (β [SE] −0.2 [0.1],  P  &lt; 0.001) and liver fat fraction (β [SE] −0.4 [0.2],  P  = 0.04) were associated with lower global well‐being score.    Conclusions  Heart failure with preserved ejection fraction patients have increased epicardial, liver, and skeletal muscle fat compared with controls out of proportion to their increased body size, and adiposity was associated with worse NYHA class and exercise tolerance in HFpEF. These results provide the basis for further investigation into the effect of interventions to reduce regional AT distribution in relation to HFpEF symptoms and pathophysiology.

Visceral adiposity, muscle composition, and exercise tolerance in heart failure with preserved ejection fraction