Pugliese NR, et al. - Via combining cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE), researchers sought to recognize early hemodynamic and metabolic alterations in patients with hypertension (HT) with and without heart failure with preserved ejection fraction (HFpEF). A symptom-limited graded ramp bicycle CPET-ESE was performed on 50 stable HFpEF-HT outpatients (mean age 68 ± 14 years) on optimal medical therapy, 63 well-controlled HT individuals (mean age 63 ± 11 years) and 32 age and gender-matched healthy controls (mean age 59 ± 15 years). Left ventricular cardiac output, global longitudinal strain, E/e′, peak oxygen consumption (VO₂), non-invasive arterial–venous oxygen content difference (AVO₂diff) and lung ultrasound B-lines were included in the acquisition protocol. Decline in peak VO₂ was observed from controls (24.4 ± 3 mL/min/kg) to HFpEF-HT (15.2 ± 2 mL/min/kg), passing through HT (18.7 ± 2 mL/min/kg). A lower peak cardiac output was evident in HFpEF-HT (9.8 ± 0.9 L/min) compared with HT (12.6 ± 1.0 L/min) and controls (13.3 ± 1.0 L/min; P = 0.01). They observed reduced peak AVO₂diff in HFpEF-HT and HT (13.3 ± 2 and 13.5 ± 2 mL/dL vs controls: 16.9 ± 2 mL/dL).