[The H2FPEF Score]: Links To And Excerpts From “A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction”

Today, I review, link to, and excerpt from [The H2FPEF Score] A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Yogesh N V Reddy 1, Rickey E Carter 2, Masaru Obokata 1, Margaret M Redfield 1, Barry A Borlaug 1. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].

All that follows is from the above resource.

Conclusion

The H2FPEF score, which utilizes six clinical and echocardiographic characteristics that are universally obtained in the evaluation of patients with unexplained exertional dyspnea, enables robust discrimination of HFpEF from non-cardiac etiologies of dyspnea at low and high scores, while identifying patients at intermediate probability where additional testing is needed to refine diagnosis.

Discussion

Heart failure with preserved ejection fraction accounts for half of HF hospitalizations, and in hospitalized patients, overt congestion is typically obvious from physical examination, chest radiography and natriuretic peptide assays. However, in outpatients with exertional dyspnea, overt congestion is often absent at rest and the diagnosis may be challenging. Right heart catheterization, with exercise if resting filling pressures are normal, is the gold standard for HFpEF diagnosis, but is not universally available, and non-invasive estimates of cardiac filling pressures lack sensitivity. In this study we derived and then validated a new score using clinical and echocardiographic variables that are widely available in clinical practice. In the derivation and test cohorts, and in sensitivity analyses restricted to community-based patients and those with early stage HFpEF, the H2FPEF score effectively discriminated patients with HFpEF from a comparator population of patients with exertional dyspnea that was not caused by heart failure, ascertained using the gold standard of invasive hemodynamic exercise testing. Inclusion of this control group was crucial to our study design, since it would not have otherwise been possible to judge the ability of clinical characteristics to estimate the likelihood of HFpEF without the ability to definitively identify or exclude disease based upon invasive criteria.

By establishing the probability of disease, the H2FPEF score may be used to effectively rule out disease among patients with low scores (e.g. 0 or 1), establish the diagnosis with reasonably high confidence at higher scores (e.g. 6–9), and identify patients where additional testing is needed with intermediate scores (e.g. 2–5). Rather than forcing a probabilistic diagnosis (HFpEF) into binary categories (present or absent), this Bayesian approach provides a framework that can be used to determine whether there is sufficient confidence in the working diagnosis, or whether further evaluation is necessary based upon the identified probability of disease. This system could be readily applied for diagnostic purposes in clinical care as well as research settings to help refine enrollment criteria for clinical trials. Although the categorical H2HPEF score is easily calculated even at the bedside to rapidly estimate low or high probability of HFpEF, the more complex continual HFPEF calculator (Online Supplement) can also be used to provide a more precise estimate of the probability of HFpEF in an individual when required for clinical use, screening or research settings.

Abstract

Background

Diagnosis of heart failure with preserved ejection fraction (HFpEF) is challenging in euvolemic patients with dyspnea, and no evidence-based criteria are available. We sought to develop and then validate non-invasive diagnostic criteria that could be used to estimate the likelihood that HFpEF is present among patients with unexplained dyspnea in order to guide further testing.

Methods

Consecutive patients with unexplained dyspnea referred for invasive hemodynamic exercise testing were retrospectively evaluated. Diagnosis of HFpEF (case) or non-cardiac dyspnea (control) was ascertained by invasive hemodynamic exercise testing. Logistic regression was performed to evaluate the ability of clinical findings to discriminate cases from controls. A scoring system was developed and then validated in a separate test cohort.

Results

The derivation cohort included 414 consecutive patients (267 HFpEF and 147 controls, HFpEF prevalence 64%). The test cohort included 100 consecutive patients (61 HFpEF, prevalence 61%). Obesity, atrial fibrillation, age>60 years, treatment with 2 or more antihypertensives, echocardiographic E/e′ ratio>9 and echocardiographic pulmonary artery systolic pressure>35 mmHg were selected as the final set of predictive variables. A weighted score based on these six variables was used to create a composite score (H2FPEF score) ranging from 0–9. The odds of HFpEF doubled for each 1 unit score increase [OR 1.98 [1.74–2.30], p<0.0001], with an AUC of 0.841 (p<0.0001). The H2FPEF score was superior to a currently-used algorithm based upon expert consensus (increase in AUC of +0.169 [+0.120 to +0.217], p<0.0001). Performance in the independent test cohort was maintained [AUC 0.886, p<0.0001].

Conclusions

The H2FPEF score, which relies upon simple clinical characteristics and echocardiography, enables discrimination of HFpEF from non-cardiac causes of dyspnea, and can assist in determination of the need for further diagnostic testing in the evaluation of patients with unexplained exertional dyspnea.

Keywords: HFpEF, exercise testing, exercise catheterization
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