Identifying diastolic dysfunction in HFpEF: a head-to-head comparison of H2FPEF and HFA-PEFF scores
M Ferreira, M I Mendonca, J A Sousa, F Escorcio Silva, G Abreu, F Sousa, G Caires, E Henriques, A Drumons FreitasAbstract
Background
The diagnosis of heart failure with preserved ejection fraction (HFpEF) remains complex due to heterogeneous clinical presentation and the absence of a universally accepted gold standard. Several diagnostic algorithms have been developed to support clinical decision-making. Currently, two scores are most frequently used: the H2FPEF score, which combines clinical variables (obesity, hypertension, atrial fibrillation, and age) with echocardiographic parameters (pulmonary hypertension and E/e′ ratio), and the HFA-PEFF score, which integrates structural and functional echocardiographic abnormalities together with natriuretic peptide levels. Although previous studies suggest different diagnostic performances for these tools depending on the reference standard used, their ability to identify diastolic dysfunction in patients with established HFpEF remains insufficiently explored.
Objective
To compare the diagnostic performance of the H2FPEF and HFA-PEFF scores in predicting diastolic dysfunction in a population with HFpEF.
Methods
A case–control study was conducted including 108 patients with HFpEF (left ventricular ejection fraction >50%). Patients were classified as cases when diastolic dysfunction was present, defined by at least two of the following echocardiographic criteria: E/e′ >14; septal e′ <7 cm/s or lateral e′ <10 cm/s; tricuspid regurgitation velocity >2.8 m/s; and left atrial volume index >34 mL/m². Patients not fulfilling these criteria were considered controls. H2FPEF and HFA-PEFF scores were calculated for all patients. Group comparisons, logistic regression analysis, and receiver operating characteristic (ROC) curves were used to assess diagnostic performance.
Results
The mean age was 68.8±10.6 years and 60.2% were female. The H2FPEF score was numerically higher in patients with diastolic dysfunction compared to controls (2.87±1.70 vs 2.29±1.65), without reaching statistical significance (p=0.076). In contrast, the HFA-PEFF score was significantly higher in cases (4.32±1.07 vs 2.53±0.84; p<0.0001). On logistic regression analysis, H2FPEF was not independently associated with diastolic dysfunction (OR 1.23; 95% CI 0.98–1.56; p=0.079), whereas HFA-PEFF showed a strong independent association (OR 6.87; 95% CI 3.44–13.69; p<0.001). ROC analysis demonstrated superior discriminatory ability of HFA-PEFF compared with H2FPEF (AUC 0.897 vs 0.595; DeLong p<0.0001).
Conclusions
In patients with HFpEF, the HFA-PEFF score showed significantly better performance than H2FPEF in identifying diastolic dysfunction. These findings support the use of HFA-PEFF as a more accurate diagnostic tool for phenotyping HFpEF in clinical practice.For image description, please refer to the figure legend and surrounding text.