OBJECTIVES: To examine the contribution of exercise echocardiography (ExE) to the diagnosis of heart failure with preserved ejection fraction (HFpEF). DESIGN: Cross-sectional study of patients undergoing ExE. PATIENTS: 436 patients with fatigue or dyspnoea presenting for ExE were studied. METHODS: Current criteria for the diagnosis of HFpEF (evidence of symptoms or signs of heart failure, EF>50%, abnormal transmitral flow and supplementary tissue Doppler measurements (E/e') suggesting raised left ventricular filling pressure) were applied to this population. The impact of reclassification of clinical status based on exercise E/e' >13 and ischaemia was evaluated. RESULTS: Of 436 patients, 37 had E/e' >15 and 111 had E/e' 8-15, with supplementary echocardiography criteria indicating HFpEF (n=148). Only 36 patients fulfilling the diagnosis of HFpEF had reduced exercise capacity. Fifteen of these patients had evidence of raised E/e' with exercise, half (7) of whom had inducible myocardial ischaemia. Of 13 patients with raised filling pressure at rest or exercise, objective exercise intolerance and no ischaemia, five did not reach the current criteria for HFpEF. CONCLUSION: The current classification for HFpEF may include patients with preserved functional status and many with ischaemia and normal exercise E/e'. Reduced exercise capacity, increase of E/e' with exercise and ischaemia are three objective aspects of the HFpEF syndrome that might be considered for incorporation in the definition.