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Diagnostic Algorithms in HFpEF
Quick Takes
- H2FPEF and HFA-PEFF scores highlight different clinical characteristics associated with increasing score, and the two scores produced discordant findings in risk classification in 28% of participants.
- Clinicians should maintain a higher degree of suspicion in detecting HFpEF in populations with unexplained shortness of breath in conjunction with the H2FPEF and HFA-PEFF algorithms.
- Validation of the algorithms in a broader community-based sample, using patients with dyspnea where HFpEF or non-HFpEF status is determined definitively by invasive assessment, is required.
Study Questions:
What are the characteristics and risk of adverse outcomes associated with the H2FPEF and HFA-PEFF scores among participants in the community with unexplained shortness of breath?
Methods:
The study authors included 4,892 ARIC (Atherosclerosis Risk in Communities) study participants, 67-90 years of age, at visit 5 (2011-2013) without other common cardiopulmonary causes of shortness of breath. They compared clinical characteristics and incidence of heart failure (HF) hospitalization or death by H2FPEF and HFA-PEFF scores among these ARIC study participants in late life self-reporting dyspnea without known common causes of shortness of breath, participants not reporting shortness of breath, and participants with known heart failure with preserved ejection fraction (HFpEF). The authors categorized the participants as asymptomatic (76.6%), having known HFpEF (10.3%), and having tertiles of each score among those with ≥moderate, self-reported shortness of breath (13.1%). The primary outcome was HF hospitalization or mortality.
Results:
The mean age of the study cohort was 75 ± 5 years, 58% were women, and 22% were black. After a mean follow-up of 5.3 ± 1.2 years, rates of HF hospitalization or death per 1,000 person-years for asymptomatic and known HFpEF were 20.7 (95% confidence interval [CI], 18.9-22.7) and 71.6 (95% CI, 61.6-83.3), respectively. Among 641 participants with unexplained shortness of breath, rates were 27.7 (95% CI, 18.2-42.1), 44.9 (95% CI, 34.9-57.7), and 47.3 (95% CI, 36.5-61.3) (tertiles of H2FPEF score) and 31.8 (95% CI, 20.3-49.9), 32.4 (95% CI, 23.4-44.9), and 54.3 (95% CI, 43.8-67.3) (tertiles of HFA-PEFF score). Participants with unexplained shortness of breath and scores above the diagnostic threshold suggested for each algorithm, H2FPEF score ≥6, and HFA-PEFF score ≥5, had equivalent risk of HF hospitalization or death compared with known HFpEF. Among those with unexplained shortness of breath, 28% had “discordant” findings (only high risk by 1 algorithm), while 4% were high risk by both. Participants with a “high H2FPEF, low HFA-PEFF score” had higher heart rate and body mass index, and more prevalent diabetes mellitus and atrial fibrillation. Those with “high HFA-PEFF, low H2FPEF score” had greater N-terminal pro–B-type natriuretic peptide, left ventricular end-diastolic diameter, and E’ velocity, and lower tricuspid regurgitation velocity and E-wave deceleration.
Conclusions:
The authors concluded that participants with unexplained shortness of breath and higher H2FPEF or HFA-PEFF scores face substantial risks of HF hospitalization or death. A significant fraction of patients are classified discordantly by using both algorithms.
Perspective:
The disparate strengths of these two independently developed algorithms to estimate risk in HFpEF probably reflects the heterogeneity of this condition and probably explains why the quest for standardized therapy remains elusive. This study suggests that prospective studies to validate such algorithms are needed.
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers
Keywords: Atrial Fibrillation, Body Mass Index, Diabetes Mellitus, Dyspnea, Geriatrics, Heart Failure, Heart Rate, Natriuretic Peptide, Brain, Peptide Fragments, Risk Assessment, Secondary Prevention, Stroke Volume, Tricuspid Valve Insufficiency
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