Comparing diagnostic tools for heart failure with preserved ejection fraction across community and clinical cohorts

Background Diagnosing heart failure with preserved ejection fraction (HFpEF) remains challenging, particularly in older adults. While the Heart Failure Association (HFA)-PEFF and H 2 FPEF Scores offer structured diagnostic approaches, their clinical utility is still debated. This study aims to compare the diagnostic accuracy of HFpEF Scores versus inclusion criteria used in sodium-glucose cotransporter-2 inhibitors (SGLT2i) trials, age-adjusted N-terminal pro B-type natriuretic peptide (NT-proBNP) thresholds and the universal definition of heart failure (HF). Methods Diagnostic tools were assessed using sex-weighted and age-weighted propensity score adjustment in individuals aged 60–80 years from two established HFpEF cohorts (MEtabolic Road to DIAstolic Heart Failure (MEDIA), n=297; Karolinska-Rennes (KaRen), n=174) and two community-based cohorts without HF (Suivi Temporaire Annuel Non-Invasif de la Santé des Lorrains Assurés Sociaux (STANISLAS), n=461; Malmö, n=1030). Results HFA-PEFF and H 2 FPEF Scores classified a large proportion of participants in both community-based cohorts (up to 81% in Malmö) and HFpEF cohorts (up to 75% in MEDIA) in the intermediate-likelihood category, requiring further diagnostic evaluation. Their diagnostic discrimination ranged from moderate to good. The universal definition of HF, SGLT2i trial criteria and NT-proBNP age-adjusted thresholds showed diagnostic performance comparable to HFA-PEFF Scores in the HFpEF cohorts and correctly excluded almost all individuals in the community cohorts. The universal definition of HF demonstrated a diagnostic discrimination higher than H 2 FPEF and comparable to HFA-PEFF, with the most balanced performance in terms of sensitivity and specificity. Conclusions Using scores, a substantial proportion of HFpEF individuals fall into the intermediate likelihood category, highlighting diagnostic uncertainty. Simpler tools, such as the universal definition of HF, demonstrate comparable or even superior diagnostic and rule-out performances for HFpEF, emphasising the need for more practical and reliable approaches to HFpEF diagnosis.