Diagnostic performance of the H2FPEF and HFA-PEFF scores in heart failure with preserved ejection fraction: a systematic review and meta-analysis

Background Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous clinical syndrome, and noninvasive diagnosis remains challenging. The H2FPEF and HFA-PEFF scores are increasingly used for diagnostic evaluation; however, their performance across clinical settings and patient subgroups has not been systematically compared. Methods We systematically searched PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to October 5, 2025. A bivariate random-effects model was applied to pool sensitivity and specificity, and hierarchical summary receiver operating characteristic (HSROC) analysis was performed for rule-out and rule-in cut-offs. Subgroup and sensitivity analyses were conducted to explore heterogeneity. Results A total of 11 studies comprising 3813 participants were included. For the H2FPEF score, the pooled sensitivity at the rule-out cut-off was 98% (95% CI, 96%–99%), and the pooled specificity at the rule-in cut-off was 90% (95% CI, 74%–97%). The HSROC area under the curve (AUC) was 0.95 (95% CI, 0.92–0.96) for the rule-out cut-off and 0.65 (95% CI, 0.61–0.69) for the rule-in cut-off. For the HFA-PEFF score, the pooled sensitivity at the rule-out cut-off was also 98% (95% CI, 95%–99%), and the pooled specificity at the rule-in cut-off was 87% (95% CI, 76%–94%), with corresponding AUCs of 0.63 (95% CI, 0.59–0.67) and 0.75 (95% CI, 0.71–0.78). Conclusion The H2FPEF score was more effective for ruling out HFpEF, whereas the HFA-PEFF score performed better for ruling in the diagnosis. Diagnostic performance varied across subgroups, with particularly cautious interpretation required in obese patients.