H2FpEF Score for Diagnosis

Study Questions:

What are the criteria that could be used to estimate the likelihood that heart failure with preserved ejection fraction (HFpEF) is present among patients with unexplained shortness of breath?


This was a retrospective analysis of all consecutive patients undergoing invasive exercise testing for the evaluation of unexplained shortness of breath between 2006 and 2016. Exclusion criteria included ejection fraction <50% (current or prior), significant valvular heart disease (> mild stenosis, > moderate regurgitation), pulmonary arterial hypertension, constrictive pericarditis, primary cardiomyopathies, or heart transplant. Diagnosis of HFpEF (case) or noncardiac dyspnea (control) was ascertained by invasive hemodynamic exercise testing. HFpEF patients were identified by elevated pulmonary capillary wedge pressure at rest (≥15 mm Hg) or during exercise (≥25 mm Hg). Noncardiac dyspnea was defined as patients with no evidence of a cardiac etiology for dyspnea after exhaustive clinical evaluation, including normal rest and exercise hemodynamics. The authors performed logistic regression to evaluate the ability of clinical findings to discriminate cases from controls. The study authors developed a scoring system and then validated it in a separate test cohort.


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%). Certain variables were highly specific for the presence of HFpEF, including grade II obesity (body mass index [BMI] >35 kg/m2, specificity 88%), chronic kidney disease (≥ stage 3, 90%), atrial fibrillation (96%), diabetes (88%), the presence of a pacemaker (99%), cardiomegaly on chest film (96%), mildly depressed EF of 50-54% (96%), E/e’ >14 (89%), pulmonary artery systolic pressure >35 mm Hg (86%), N-terminal pro–B-type natriuretic peptide (NT-proBNP) >450 pg/ml (85%), and the presence of right ventricular dysfunction. The final set of predictive variables selected were obesity (BMI >30 kg/m2), atrial fibrillation, age >60 years, treatment with ≥2 antihypertensive medications, echocardiographic E/e’ ratio >9, and echocardiographic pulmonary artery systolic pressure >35 mm Hg (all p < 0.05).

Based on these six variables, a composite score (H2FPEF score) was created ranging from 0-9 (see Figure 1 in the article). The odds of HFpEF doubled for each 1 unit score increase (odds ratio, 1.98 [1.74-2.30], p < 0.0001), with an area under the curve (AUC) of 0.841 (95% confidence interval [CI], 0.802-0.881; p < 0.0001). The H2FPEF score better discriminated HFpEF from noncardiac causes of dyspnea compared to widely used diagnostic algorithms based on expert consensus (AUC comparison +0.169 [95% CI, +0.120 to +0.217] vs. 2016 European Society of Cardiology [ESC] guidelines and +0.173 [95% CI, +0.132 to +0.215] vs. 2007 ESC guidelines; both p < 0.0001). The use of NT-proBNP levels did not incrementally add diagnostic ability to the H2FPEF score. Performance in the independent test cohort was maintained (AUC, 0.886; p < 0.0001).


The authors concluded that this H2FPEF score, which relies on simple clinical characteristics and echocardiography, enables discrimination of HFpEF from noncardiac causes of dyspnea, and can assist in determination of the need for further diagnostic testing in the evaluation of patients with unexplained exertional shortness of breath.


The authors of this study should be congratulated on developing this bedside score to determine the probability of HFpEF. Prospective studies are now needed to determine its utility in the evaluation of such patients.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Noninvasive Imaging, Pulmonary Hypertension and Venous Thromboembolism, Anticoagulation Management and Atrial Fibrillation, Atrial Fibrillation/Supraventricular Arrhythmias, Acute Heart Failure, Heart Failure and Cardiac Biomarkers, Pulmonary Hypertension, Echocardiography/Ultrasound

Keywords: Antihypertensive Agents, Atrial Fibrillation, Blood Pressure, Body Mass Index, Cardiomegaly, Diabetes Mellitus, Diagnostic Imaging, Dyspnea, Echocardiography, Exercise Test, Geriatrics, Heart Failure, Natriuretic Peptide, Brain, Obesity, Pacemaker, Artificial, Peptide Fragments, Hypertension, Pulmonary, Renal Insufficiency, Chronic, Stroke Volume, Ventricular Dysfunction, Right

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