Identification of HFpEF using the H2FPEF score in consecutively admitted patients without a primary heart failure diagnosis

Introduction

The 2021 ESC Heart Failure Guidelines recommend a structured diagnostic approach for heart failure with preserved ejection fraction (HFpEF), including clinical assessment, echocardiography, and natriuretic peptides. Diagnostic scores such as the H2FPEF score may support HFpEF identification in patients with symptoms suggestive of heart failure. Nowadays, when we have effective treatments that reduce mortality and morbidity in HFpEF, early diagnosis of patients is essential. However, HFpEF diagnosis can be challenging, particularly in patients admitted without a primary heart failure diagnosis.

Aim

To evaluate the proportion of HFpEF in consecutive cohort of patients without a primary diagnosis of heart failure but presenting symptoms suggestive heart failure (dyspnea, fatigue) using the H2FPEF score.

Patients and methods: Data were obtained from a consecutive cohort of 446 patients admitted to a tertiary cardiology center in January 2025. Patients with a left ventricular ejection fraction below 50% and those whose primary referral diagnosis was heart failure were excluded from the evaluation (104 pts). Thirteen patients were excluded because we did not have their left ventricular ejection fraction values. Finally, 174 patients were excluded from the study due to the absence of symptoms characteristic of heart failure. The H2FPEF score was calculated for remaining 155 patients. Relevant clinical and echocardiographic information was extracted from medical records.

Results

The main characteristics of the 155 patients evaluated were as follows: age: 66.6 (±13.5) years, male: 63.9 %, LVEF: 59.2 (±6.4) %, body mass index (BMI): 28.8 (±5.7) kg/m2, pulmonary artery systolic pressure (PASP): 35.3 (±12.0) mmHg, Doppler echocardiographic E/e’: 10.1 ±3.6. Patients were admitted for electrophysiological evaluation (25.2 %), due to acute coronary syndrome, coronary angiography and/or intervention (63.9 %), valvular reasons (7.1 %), or other indications (3.8 %). Within the cohort, 71.6 % were over 60 years of age, 92.3 % were hypertensive and 23.2 % had atrial fibrillation. A BMI above 30 kg/m² was observed in 36.4 % of the population, while PASP exceeded 35 mmHg in 40.2 %, and 65.4 % had an E/e' ratio greater than 9. When calculating the H2FPEF score, we found a value of 0-1 in 21 patients (13.6%), a value of 2-5 in 98 patients (63.2%), and a value of 6-9 in 36 patients (23.2%).

Conclusions

Based on our findings, it is essential to consider the diagnosis of HFpEF in patients admitted to hospital with a primary diagnosis other than heart failure but who show symptoms of heart failure. In our study, using the H2FPEF score, we found HFpEF in nearly a quarter of patients, and nearly two-thirds of patients require further diagnostic evaluation to evaluate HFpEF. Routine assessment of the score parameters eases diagnosis, helps identify HFpEF within this patient population, and supports early intervention and management.