Modeling heart failure with preserved ejection fraction (HFpEF) likelihood among women with suspected coronary microvascular dysfunction (CMD)

Q: What are the key findings of this study?

Among women with suspected INOCA, 56% had an intermediate or high probability of HFpEF, with compromised microvascular perfusion, physical limitation, and diabetes emerging as independent predictors of a higher H2FPEF score.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected ischemia and no obstructive coronary arteries (INOCA) (n=98). Intervention: Coronary microvascular dysfunction (CMD) parameters vs. Normal microvascular function or lower H2FPEF risk profile. Primary outcome: H2FPEF score (estimate of HFpEF likelihood).

Q: What does this research mean for the field?

Among women with suspected INOCA, over half have an intermediate or high probability of HFpEF by H2FPEF score, which is independently predicted by compromised microvascular perfusion, physical limitation, and diabetes. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Zev Allison; Sachini Ranasinghe; Jenna Maughan; Okezi Obrutu; Galen Cook‐Wiens; Ana Iribarren; Alan Kwan; Michael Nelson; Debiao Li; Martha Gulati; C. Noel Bairey Merz; Janet Wei

doi:10.1016/j.ahjo.2026.100925

September 1, 2026American Heart Journal Plus Cardiology Research and PracticeOpen Access

Modeling heart failure with preserved ejection fraction (HFpEF) likelihood among women with suspected coronary microvascular dysfunction (CMD)

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Key result

Nearly ~56% of women with suspected INOCA have an intermediate-to-high HFpEF likelihood linked to microvascular dysfunction.

n=98

Why the study?

The H2FPEF score has not been evaluated among women with suspected INOCA to estimate HFpEF likelihood despite CMD potentially preceding HFpEF development.

Do markers of coronary microvascular dysfunction predict an increased likelihood of HFpEF (H2FPEF score) in women with suspected INOCA?

Key Points

To evaluate the likelihood of heart failure with preserved ejection fraction (HFpEF) using the H2FPEF score among women with suspected ischemia and no obstructive coronary artery disease (INOCA).
Analyzed 98 women with suspected INOCA enrolled in prospective cohort studies at a single center (Cedars-Sinai Medical Center).
Evaluated left ventricular structure, function, myocardial perfusion reserve index (MPRI), and fibrosis using 3 Tesla cardiac magnetic resonance imaging (CMR) alongside echocardiography to calculate H2FPEF scores.
Assessed associations using Spearman correlation, multivariable linear regression, and multivariable logistic regression models.
The median H2FPEF score was 2 (range 0–7), with 44% (n=43) categorized as low probability, 54% (n=53) as intermediate probability, and 2% (n=2) as high probability of HFpEF.
H2FPEF score was inversely correlated with MPRI (r = −0.27, p = 0.007), native T1, extracellular volume, and Seattle Angina Questionnaire (SAQ) physical limitation score (all p < 0.05).
Multivariable linear regression identified low MPRI, SAQ physical limitation, and history of diabetes as independent predictors of higher H2FPEF scores (model R-squared 0.31).

Study Design

Type

Cohort (n=98)

Multicenter

No

Structured PICO

Do markers of coronary microvascular dysfunction predict an increased likelihood of HFpEF (H2FPEF score) in women with suspected INOCA?

P

Population

98 women with suspected INOCA who underwent cardiac magnetic resonance imaging and echocardiography to evaluate predictors of the H2FPEF score.

E

Exposure

Coronary microvascular dysfunction (CMD) parameters evaluated by cardiac magnetic resonance imaging (e.g., myocardial perfusion reserve index, native T1, extracellular volume).

O

Outcome

H2FPEF score (estimate of HFpEF likelihood) evaluated continuously and categorically (low 0-1, intermediate 2-5, high 6-9 probability).surrogate

Coronary microvascular dysfunction is associated with higher estimated likelihood of HFpEF in women with INOCA, supporting a potential mechanistic link between CMD and HFpEF pathogenesis.

Limitations

Data from a single center
Limited to women
Retrospective evaluation of echocardiograms, which may contribute selection bias
Missing echocardiographic data was counted as normal, potentially underestimating the H2FPEF score
Cannot establish causality or temporal direction due to cross-sectional analysis
Single center
Retrospective evaluation of echo data
Selection bias from clinical echo availability
Missing echo data assumed normal
Cross-sectional design cannot establish causality

Implication

Supports HFpEF evaluation in INOCA women with CMD; hypothesis-generating for mechanistic overlap, needs prospective validation.

Abstract

Background Coronary microvascular dysfunction (CMD) can precede development of heart failure with preserved ejection fraction (HFpEF) in patients with ischemia and no obstructive coronary arteries (INOCA). The H2FPEF score is used to estimate HFpEF likelihood but has not been evaluated among women with suspected INOCA. Methods Women ( n = 98) with suspected INOCA enrolled in prospective cohort studies at a single center with both cardiac magnetic resonance imaging (CMR) and echocardiography to calculate H2FPEF score. CMR evaluated left ventricular (LV) structure, function, myocardial perfusion reserve index (MPRI) and fibrosis. Spearman correlation and multivariable linear regression were performed. Results Group mean age was 56 years, BMI 27 kg/m 2 , 39% had hypertension, and 12% had diabetes. Median H2FPEF score was 2 (range 0–7), with 43 (44%), 53 (54%), and 2 (2%) ranked as having low (0–1), intermediate (2–5), or high (6–9) probability of HFpEF, respectively. H2FPEF score was inversely related to MPRI, native T1, extracellular volume, and Seattle Angina Questionnaire (SAQ) physical limitation score (all p < 0.05), but not related to LV strain or remodeling. Regression modeling demonstrated that low MPRI, SAQ physical limitation, and diabetes were independent predictors of H2FPEF, adjusted for dyslipidemia and native T1. Conclusions Among women with suspected INOCA, 54% had an intermediate or higher H2FPEF score. Compromised microvascular perfusion, fibrosis, angina, and history of diabetes predicted H2FPEF score. These findings support the hypothesis that CMD may contribute to development of HFpEF in women with INOCA. Longitudinal studies and intervention trials are needed.

Discussion

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Cite This Study

Allison et al. (2026) conducted a cohort in Suspected ischemia and no obstructive coronary arteries (INOCA) (n=98). Coronary microvascular dysfunction (CMD) parameters vs. Normal microvascular function or lower H2FPEF risk profile was evaluated on H2FPEF score (estimate of HFpEF likelihood). Among women with suspected INOCA, 56% had an intermediate or high probability of HFpEF, with compromised microvascular perfusion, physical limitation, and diabetes emerging as independent predictors of a higher H2FPEF score.

synapsesocial.com/papers/6ac19d70aeea5716e8c6c671 https://doi.org/10.1016/j.ahjo.2026.100925

Topics

HFrEF treatment

Heart failure

Coronary artery disease

HFpEF management

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Modeling heart failure with preserved ejection fraction (HFpEF) likelihood among women with suspected coronary microvascular dysfunction (CMD)

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

Topics

Modeling heart failure with preserved ejection fraction (HFpEF) likelihood among women with suspected coronary microvascular dysfunction (CMD)

Key Points

Study Design

Structured PICO

Limitations

Implication

Abstract

Discussion

Cite This Study

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Topics

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