Exercise-Based Management of Diabetic Cardiomyopathy: Preclinical Mechanisms, Clinical Evidence, and Translational Strategies.

Diabetic cardiomyopathy is characterized by progressive metabolic dysfunction, myocardial fibrosis, impaired calcium handling, and ventricular remodeling, yet effective strategies for reversing established cardiac injury remain limited. Exercise training has emerged as a promising non-pharmacological approach, although its clinical application is constrained by heterogeneous intervention protocols, inconsistent dose reporting, and limited evidence from well-characterized diabetic cardiomyopathy populations. This narrative review synthesizes current preclinical and clinical evidence on exercise-based management of diabetes-associated myocardial dysfunction, with particular emphasis on underlying mechanisms, exercise prescription, and translational implementation. Experimental studies indicate that exercise may improve myocardial function through enhanced mitochondrial biogenesis and metabolic flexibility, attenuation of oxidative stress and inflammatory-fibrotic signaling, restoration of calcium homeostasis, and regulation of apoptosis, pyroptosis, and microRNA-related pathways. Clinical evidence, derived predominantly from individuals with Type 2 diabetes and subclinical or early cardiac abnormalities, suggests that combined aerobic and resistance training can improve cardiorespiratory fitness, insulin sensitivity, vascular function, and selected indices of left ventricular performance. High-intensity interval training may provide additional benefits in appropriately selected patients, but its safety and effectiveness require individualized assessment. To improve translation, exercise intensity should be reported using physiologically comparable metrics, while treatment response should be evaluated through integrated measures of cardiac imaging, functional capacity, biomarkers, glycemic control, and adverse events. Overall, exercise represents a biologically plausible and clinically relevant adjunctive strategy for diabetic cardiomyopathy, particularly in early-stage disease; however, adequately powered trials in clearly defined patient populations are still needed to establish optimal dose, safety, and long-term cardiovascular benefit.