Determines probability of diagnosis of heart failure with preserved EF in patients with exertional dyspnea.
See the text below the score for more information on HFpEF diagnosis and the development and validation of the score.
The H2FPEF score relies on clinical and echocardiographic characteristics that are universally obtained in the evaluation of patients presenting with unexplained exertional dyspnea, to discriminate HFpEF from noncardiac causes of dyspnea.
Diagnosing HFpEF relies upon the presence of symptoms and/or signs of heart failure, preserved left ventricular systolic function, and evidence of diastolic dysfunction, via echocardiography (E/e’) and biomarkers (NT-proBNP).
The H2FPEF score may be used to effectively rule out disease among patients with low probabilities, to establish the diagnosis with reasonably high confidence at higher probabilities, and to identify patients for whom additional testing is required (intermediate probabilities).
Formula for probability of heart failure with preserved ejection fraction: (Z / (1 + Z)) x 100
Where: Z = ey and
y = -9.1917 + 0.0451 x age + 0.1307 x BMI + 0.0859 x E/e' ratio + 0.0520 x pulmonary artery systolic pressure + 1.6997 x atrial fibrillation (1 for Yes and 0 for No)
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1. H2FPEF Calculator
2. H2FPEF Score explained
3. About the original study
4. References
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(E/e’) ratioEarly mitral inflow velocity/mitral annular early diastolic velocity (E/e’) ratio
Pulmonary artery systolic pressure (from echo)
Atrial fibrillation (from clinical history and EKG)
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H2FPEF Score explained
The H2FPEF Score can be used in the diagnosis of heart failure with preserved ejection fraction (HFpEF) in euvolemic patients with unexplained exertional dyspnea by enabling discrimination of HFpEF from noncardiac causes of dyspnea.
Currently, diagnosing HFpEF relies upon the presence of symptoms and/or signs of heart failure, preserved left ventricular systolic function, and evidence of diastolic dysfunction, via echocardiography (E/e’) and biomarkers (NT-proBNP).
The H2FPEF Score consists of 5 variables:
- Patient age;
- Patient BMI;
- Early mitral inflow velocity/mitral annular early diastolic velocity (E/e') ratio;
- Pulmonary artery systolic pressure (from echo;
- Atrial fibrillation (from clinical history and EKG).
These are then used to calculate the probability of heart failure with preserved ejection fraction as follows: (Z / (1 + Z)) x 100 where Z = ey and
y = -9.1917 + 0.0451 x age + 0.1307 x BMI + 0.0859 x E/e' ratio + 0.0520 x pulmonary artery systolic pressure + 1.6997 x atrial fibrillation (1 for Yes and 0 for No)
The original study also described a simpler method with addition of points and dichotomous variables (see table below), however the formula with the continuous variables presented above was found to be more accurate and is recommended.
| Clinical variable | Values | Points | |
| H2 | Heavy | BMI > 30kg/m2 | 2 |
| Hypertensive | 2 or more antihypertensive medicines | 1 | |
| F | Atrial Fibrillation | Paroxysmal or Persistent | 3 |
| P | Pulmonary Hypertension | Doppler Echocardiographic estimated Pulmonary Artery Systolic Pressure > 35 mmHg | 1 |
| E | Elder | Age > 60 years | 1 |
| F | Filling Pressure | Doppler Echocardiographic E/e' > 9 | 1 |
The probability of HFpEF increased with increasing H2FPEF score. The H2FPEF score may be used to effectively rule out disease among patients with low scores of 0 or 1, to establish the diagnosis with reasonably high confidence at higher scores of 6 to 9, and to identify patients for whom additional testing is required (intermediate scores: 2–5).
About the original study
Diagnosing HFpEF (which accounts for half of heart failure hospitalizations) in outpatients with exertional dyspnea can be challenging, as overt congestion is often absent at rest. While right-sided heart catheterization, including exercise testing when resting filling pressures are normal, is considered the gold standard for HFpEF diagnosis, it is not universally accessible, and noninvasive methods for estimating cardiac filling pressures lack sensitivity.
To address this issue, the 2018 study developed and validated a new scoring system that utilizes clinical and echocardiographic variables readily available in clinical practice.
The derivation cohort included 414 consecutive patients (267 cases with HFpEF and 147 controls; HFpEF prevalence, 64%) and the test cohort consisted of 100 consecutive patients (61 with HFpEF; 39 controls; prevalence, 61%).
The score effectively distinguished patients with HFpEF from a comparator group of patients with exertional dyspnea unrelated to heart failure, as confirmed by invasive hemodynamic exercise testing.
The variables identified through univariable screening were entered into a multivariable model. The H2FPEF score (points based model) provided strong discrimination of HFpEF from controls (AUC, 0.841; 95% CI, 0.802–0.881). The continual scale (formula model) resulted in a slightly better-performing model (AUC comparison, 0.022; 95% CI, 0.002–0.042; P=0.03. The number of hypertension medicines did not remain predictive in the continuous model, so this variable was eliminated.
The H2FPEF score better discriminated HFpEF from noncardiac causes of dyspnea compared with widely used diagnostic algorithms based on expert consensus.
The H2FPEF score relies on clinical and echocardiographic characteristics that are universally obtained in the evaluation of patients presenting with unexplained exertional dyspnea, to discriminate HFpEF from noncardiac causes of dyspnea.
References
Original reference
Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure with Preserved Ejection Fraction. Circulation. 2018; 138(9).
Other references
Paulus WJ. H2FPEF Score: At Last, a Properly Validated Diagnostic Algorithm for Heart Failure With Preserved Ejection Fraction. Circulation. 2018; 138(9):871-873.
Huis In 't Veld AE, de Man FS, van Rossum AC, Handoko ML. How to diagnose heart failure with preserved ejection fraction: the value of invasive stress testing. Neth Heart J. 2016; 24(4):244-51
