H ₂ FPEF Score

At Last, a Properly Validated Diagnostic Algorithm for Heart Failure With Preserved Ejection Fraction Article, see p 861 O ver the past 3 decades, the prevalence of heart failure with preserved ejection fraction (HFpEF) relative to total heart failure prevalence rose from 41% to 56%. 1 Simultaneously, the prevalence of heart failure with reduced ejection fraction and heart failure with midrange ejection fraction fell from 44% to 31% and from 15% to 13%, respectively. 1Despite this alarming increase in HFpEF prevalence, a reference strategy to establish the diagnosis of HFpEF is still lacking.As a consequence, trials continue to recruit patients with HFpEF by using a wide array of criteria and cutoff values.To remediate the confusion, professional societies such as the European Society of Cardiology and the American Society of Echocardiography issued several consensus statements providing diagnostic guidelines or recommendations for HFpEF.These statements were frequently met by skepticism qualifying them as overcomplicated and even triggered disbelief in the existence of HFpEF: "If HFpEF is that difficult to diagnose, it does not exist!"On top of symptoms and signs of volume overload and a preserved ejection fraction, the diagnostic strategies recommended by the professional societies all consisted of similar elements: evidence of (1) structural left ventricular (LV) remodeling based on left atrial (LA) volume index or LV mass; (2) diastolic LV dysfunction based on early diastolic mitral inflow velocity (E), early diastolic mitral annular tissue velocity (e), and the ratio thereof (E/e); (3) pulmonary hypertension based on peak tricuspid regurgitation velocity; and (4) increased myocardial wall stress based on plasma levels of natriuretic peptides.Over the past decade, these elements have been repeatedly reshuffled like a deck of cards to yield yet another algorithm.Major issues involving the diagnosis of HFpEF remained unaddressed, however.These consisted of (1) distinct clinical phenotypes predisposing to HFpEF, such as obesity, diabetes mellitus, and chronic kidney disease 2,3 ; (2) existence of an early stage of HFpEF whereby patients present with normal LV filling pressures at rest but a brisk rise of filling pressures during exercise 4 ; and (3) a specific plasma biomarker profile that differs from heart failure with reduced ejection fraction and frequently features normal or minimally raised levels of natriuretic peptides. 5The study by Reddy et al 6 in this issue of Circulation addresses these issues and proposes to diagnose HFpEF in symptomatic euvolemic patients by using a H 2 FPEF score derived from dichotomized variables, or a HFpEF nomogram derived from continuous variables (Figure II in the online-only Data Supplement of the study by Reddy et al 6 ).The H 2 FPEF score and HFpEF nomogram were based on simple clinical and echocardiographic characteristics that served as variables in a logistic regression analysis.This analysis evaluated their ability to discriminate noncardiac dyspnea from HFpEF, both rigorously established using invasive hemodynamic exercise testing. 4The H 2 F-PEF score and the HFpEF nomogram were subsequently validated in a separate