Abstract
Heart failure with preserved ejection fraction (HFpEF) is a complex systemic syndrome characterized by severe exercise intolerance. In addition to cardiac dysfunction, abnormalities in peripheral skeletal muscle are key contributors to reduced exercise capacity in HFpEF. Multiple studies show that exercise training and caloric restriction improve exercise capacity and quality of life in HFpEF patients. To map the HFpEF-associated molecular signatures in skeletal muscle and the effect of lifestyle intervention, we generated single-nucleus (sn) multiome (joint snRNA-seq and snATAC-seq) profiles of 140 biopsies. Our study included 95 individuals: 25 healthy controls and 70 HFpEF patients, of whom 45 had paired biopsies collected before and after a supervised diet and exercise intervention. From 132,568 nuclei, we resolved 15 skeletal muscle cell types and identified HFpEF-specific remodeling, including type 1 fiber and pericyte depletion and type 2x fiber enrichment, reflecting the cellular basis of exercise intolerance. Transcriptional changes in HFpEF muscle indicated dysregulation of metabolic pathways, stress-responsive programs, cytoskeletal integrity, and calcium signaling. Transcription factor (TF) motifs enriched in differentially accessible chromatin corresponded to concordantly differentially expressed TF-genes, revealing coordinated regulatory programs underlying these changes. Importantly, HFpEF-related changes in both chromatin accessibility and transcription were partially reversible following diet and exercise. Integrative multiomic velocity analyses revealed increased coordinated repression in both chromatin accessibility and transcription of calcium handling genes in HFpEF. HFpEF-linked chromatin was enriched for HF and cardiometabolic GWAS signals, and cross-modal analyses further nominated candidate causal variants and effector genes linking genetic risk to peripheral muscle dysfunction in HFpEF. Together, these findings highlight the molecular mechanisms underlying skeletal muscle remodeling in HFpEF and identify pathways responsive to lifestyle interventions.