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Original Article • Arq. Bras. Cardiol. 122 (6) • May 2025 • https://doi.org/10.36660/abc.20240852i linkcopy

Prognostic Applications of Current Clinical Scores in Heart Failure with Preserved Ejection Fraction: A Prospective Cohort Study

Authorship SCIMAGO INSTITUTIONS RANKINGS

Background The H2FPEF and HFA-PEFF scores were developed to support the diagnosis of heart failure with preserved ejection fraction (HFpEF) and may also help predict cardiovascular outcomes.

Objective To assess the prognostic value of these scores in a cohort of individuals with HFpEF.

Methods This prospective study was conducted at a tertiary hospital in Brazil between March 2019 and December 2021. After clinical evaluation, echocardiography, and exercise testing, the H2FPEF and HFA-PEFF scores were calculated. Patients were classified into intermediate probability groups (H₂FPEF: 2-5 points; HFA-PEFF: 2-4 points) and high probability groups (H2FPEF >5 points; HFA-PEFF >4 points). The primary outcome was a composite of all-cause mortality and hospitalizations due to HFpEF. Statistical significance was set at p<0.05.

Results A total of 103 patients were followed for an average of 888 days (±291). The mean age was 69 years (±8.3), and 61% were women. Twenty-seven patients (26.2%) experienced primary outcomes, totaling 32 events—11 deaths and 21 hospitalizations due to HFpEF. In the receiver operating characteristic (ROC) curve analysis, the H₂FPEF score showed better predictive ability for the outcomes (area under the curve [AUC]: 0.637, 95% CI: 0.518–0.756, p=0.035) compared to the HFA-PEFF score (AUC: 0.572, 95% CI: 0.448–0.696, p=0.270). In the Kaplan-Meier analysis, high-probability classification by both scores was significantly associated with the occurrence of outcomes (log-rank p=0.034), compared to the intermediate score group or patients with differing classifications between the two scores.

Conclusions The H₂FPEF score showed better performance than the HFA-PEFF score in predicting outcomes in patients with HFpEF. Findings from this contemporary study conducted in Brazil contribute to risk stratification in clinical practice.

Diagnosis; Heart Failure; Prognosis

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Central Illustration:
Prognostic Applications of Current Clinical Scores in Heart Failure with Preserved Ejection Fraction: A Prospective Cohort Study

Prognostic application of the H₂FPEF and HFA-PEFF scores in patients with HFpEF.

Variable	H₂FPEF intermediate (n=47)	H₂FPEF high (n=56)	p-value	HFA-PEFF intermediate (n=41)	HFA-PEFF high (n=61)	p-value
Age (years)	68.6 (8.4)	69.4 (8.3)	0.632	69.0 (7.4)	69.4 (8.6)	0.804
Female sex, n (%)	33 (70%)	30 (54%)	0.106	27 (66%)	36 (59%)	0.537
Prior HF hospitalizations, n (%)	14 (30%)	43 (77%)	<0.001	26 (63%)	30 (49%)	0.223
Comorbidities, n (%)
Obesity	36 (77%)	42 (75%)	1.000	33 (80%)	44 (72%)	0.360
Hypertension	47 (100%)	53 (95%)	0.248	39 (95%)	60 (98%)	0.563
Diabetes mellitus	30 (64%)	28 (50%)	0.170	23 (56%)	35 (57%)	1.000
Atrial fibrillation or flutter	3 (6%)	46 (82%)	<0.001	19 (46%)	29 (47%)	1.000
Coronary artery disease	19 (40%)	18 (32%)	0.415	12 (29%)	25 (41%)	0.295
Chronic kidney disease	20 (43%)	22 (39%)	0.841	18 (44%)	24 (39%)	0.685
Lifestyle habits, n (%)
Physical activity	15 (32%)	12 (21%)	0.265	7 (17%)	19 (31%)	0.164
Smoking	26 (55%)	34 (61%)	0.689	23 (56%)	36 (59%)	0.839
MLHFQ score	33.2 (22.8)	33.4 (20.2)	0.969	35.9 (21.2)	31.5 (21.5)	0.325
Medications in use, n (%)
Beta-blockers	43 (91%)	46 (82%)	0.249	35 (85%)	53 (87%)	1.000
ACE inibitors/ARB	36 (77%)	47 (84%)	0.454	33 (80%)	49 (80%)	1.000
Spironolactone	8 (17%)	8 (14%)	0.788	6 (15%)	9 (15%)	1.000
Loop diuretic	22 (47%)	39 (70%)	0.027	23 (56%)	37 (61%)	0.685
Laboratory tests
Creatinine clearance (mL/min)	62.7 (19.4)	58.1 (17.8)	0.220	59.0 (20.9)	60.6 (16.9)	0.668
Hemoglobin (g/dL)	12.9 (1.4)	13.1 (1.6)	0.550	12.8 (1.5)	13.2 (1.5)	0.296
Natriuretic peptides
NT-proBNP, median (pg/mL) (n=55)	225.7 (152.0-326.6)	695.1 (329.4-1.725.0)	<0.001	158.6 (121.2-308.3)	447.6 (246.4-1.318.2)	0.011
BNP, median (pg/mL) (n=28)	86.9 (31.5-123.9)	147.4 (118.1-273.2)	0.002	70.2 (23.5-144.0)	126.8 (89.2-190.4)	0.035
Anthropometric measurements
BMI (kg/m2)	34.0 (5.7)	33.3 (5.3)	0.529	34.4 (6.0)	33.1 (5.1)	0.249
Lean mass (%)	58.2 (8.5)	62.2 (12.1)	0.054	58.9 (10.6)	61.3 (10.9)	0.277

Variable	H₂FPEF intermediate (n=47)	H₂FPEF high (n=56)	p-value	HFA-PEFF intermediate (n=41)	HFA-PEFF high (n=61)	p-value
Echocardiography
LV mass (g/m²)	92.4 (24.0)	98.2 (22.1)	0.207	90.8 (21.6)	98.9 (23.7)	0.082
Septal wall thickness (mm)	10.5 (1.5)	10.9 (1.5)	0.174	10.7 (1.5)	10.7 (1.6)	0.804
Posterior wall thickness (mm)	10.0 (1.4)	10.3 (1.6)	0.311	10.0 (1.5)	10.3 (1.5)	0.365
RWT	0.43 (0.07)	0.43 (0.07)	0.761	0.44 (0.08)	0.43 (0.06)	0.624
Ejection fraction (%)	61.5 (4.4)	58.4 (4.3)	0.001	58.9 (5.2)	60.5 (4.0)	0.090
Indexed LA volume (mL/m²)	41.8 (9.8)	53.8 (16.0)	<0,001	45.3 (12.8)	50.8 (15.4)	0.061
Indexed RA volume (mL/m²)	31.1 (15.2)	44.4 (20.9)	<0,001	34.5 (14.7)	41.5 (22.4)	0.082
RV basal diameter (mm)	36.5 (3.8)	39.4 (5.3)	0.002	38.8 (4.6)	37.4 (5.0)	0.157
TAPSE (mm)	20.2 (3.9)	17.3 (4.0)	<0,001	17.9 (4.2)	19.1 (4.1)	0.147
FAC (%)	44.4 (5.6)	42.2 (5.8)	0.069	43.1 (6.6)	43.3 (5.2)	0.879
PASP (mmHg)	28.6 (5.1)	37.3 (10.7)	<0,001	32.9 (8.6)	35.2 (10.8)	0.310
Central venous pressure (mmHg)	4.5 (2.3)	6.9 (4.3)	<0,001	5.8 (3.4)	5.8 (4.0)	0.974
Septal e’ wave (cm/s)	5.7 (1.4)	6.9 (2.0)	0.001	6.6 (2.3)	6.2 (1.5)	0.310
Lateral e’ wave (cm/s)	7.1 (1.8)	9.3 (2.9)	<0.001	9.0 (2.7)	7.8 (2.5)	0.020
E/e’ ratio	13.1 (4.7)	13.2 (6.2)	0.926	12.5 (5.6)	13.6 (5.4)	0.323
Cardiopulmonary exercise testing
Peak HR (% of predicted)	81.5 (12.3)	85.7 (17.1)	0.159	87.0 (13.6)	81.3 (15.7)	0.071
Peak VO₂ (mL/kg/min)	15.1 (2.5)	14.7 (3.2)	0.465	14.4 (2.9)	15.1 (2.9)	0.245
Peak VO₂ (% of predicted)	80.5 (14.8)	74.0 (15.2)	0.033	75.4 (12.9)	78.2 (16.8)	0.380
VE/VCO₂ slope	33.2 (7.7)	38.5 (8.8)	0.002	35.7 (9.0)	36.3 (8.6)	0.723
Peak VE/VCO₂	32.5 (6.5)	36.9 (5.5)	0.001	34.9 (7.0)	34.6 (6.0)	0.827
PetCO₂ (mmHg)	32.4 (4.4)	30.8 (4.2)	0.085	32.5 (4.2)	30.9 (4.4)	0.088

Variables	Intermediate score	High score	p-value
H₂FPEF score (n=103)	47 (46%)	56 (54%)
Total score	4.3 (0.9)	7.3 (1.1)	<0.001
Obesity	35 (74%)	42 (75%)	1
Use of ≥2 antihypertensives	44 (94%)	49 (87%)	0.339
AF	3 (6%)	46 (82%)	<0.001
Age >60 years	38 (81%)	49 (87%)	0.419
E/e’ ratio >9	40 (85%)	40 (71%)	0.153
PSAP >35 mmHg	3 (6%)	32 (57%)	<0.001
PASP unavailable	16 (34%)	4 (7%)	0.001
HFA-PEFF score (n=102)	41 (40%)	61 (59%)
Total score	3.6 (0.7)	5.7 (0.5)	<0.001
Functional domain*
Septal e’ <7 cm/s	27 (66%)	44 (72%)	0.518
Lateral e’ <10 cm/s	29 (71%)	49 (80%)	0.342
Average E/e’ >15	9 (22%)	19 (31%)	0.369
Average E/e’ 9-14	20 (49%)	32 (52%)	0.840
TR velocity >2.8 m/s	13 (32%)	23 (38%)	0.673
TR velocity unavailable	5 (12%)	15 (25%)	0.137
Morphological domain
LA volume >34 mL/m2	34 (83%)	58 (95%)	0.085
LA volume 29-34 mL/m2	3 (7%)	3 (5%)	0.682
LV mass >149/122 g/m2 (M/F) + RWT >0.42	1 (2%)	5 (8%)	0.397
LV mass >115/95 g/m2 (M/F)	10 (24%)	22 (36%)	0.278
RWT >0.42	19 (46%)	34 (56%)	0.420
Wall thickness >12 mm	8 (19%)	17 (28%)	0.360
Natriuretic peptides
NT-proBNP >220 / BNP >80 (without AF)	0 (0%)	33 (54%)	<0.001
NT-proBNP 125–220 / BNP 35–80 (without AF)	2 (5.0%)	9 (15%)	0.192
NT-proBNP >660 / BNP >240 (with AF)	2 (5.0%)	13 (21%)	0.024
NT-proBNP 365–660 / BNP 105–240 (with AF)	1 (2%)	6 (10%)	0.237
Did not meet criteria	16 (39%)	0 (0%)	<0.001
Peptide not collected	20 (49%)	0 (0%)	<0.001

Variable	Total HFpEF (n=103)	H2FPEF intermediate (n=47)	H2FPEF high (n=56)	p-value	HFA-PEFF intermediate (n=41)	HFA-PEFF high (n=61)	p-value
Patients with primary outcomes, n (%)	27 (26%)	7 (15%)	20 (36%)	0.024	8 (19%)	19 (31%)	0.254
H₂FPEF score	6.5 (1.6)	4.4 (0.8)	7.3 (1.1)		6.6 (1.7)	6.5 (1.6)
HFA-PEFF score	5.2 (1.0)	5.4 (1.0)	5.1 (1.1)		3.8 (0.5)	5.8 (0.4)
Primary outcome events, n	32	10	22		9	23
Death, n (%)	11 (11%)	5 (11%)	6 (11%)	0.990	3 (7.3%)	8 (13%)	0.518
HF hospitalizations, n (%)	21 (20%)	5 (11%)	16 (29%)	0.029	6 (15%)	15 (25%)	0.318
MAGGIC score (mean±SD)	17.3 (4.7)	16.9 (4.5)	17.7 (5.0)	0.420	17.3 (4.6)	17.5 (4.7)	0.800

Variables	Total HFpEF (n=103)	Both intermediate (n=18)	Discordant scores (n=53)	Both high (n=32)	p-value
Patients with primary outcome, n (%)	27 (26%)	2 (11%)	11 (20,7%)	14 (44%)	<0.007
H₂FPEF score	6,5 (1,6)	4,5 (0,7)	6,0 (1,84)	7.3 (1,1)
HFA-PEFF score	5,2 (1,0)	4,0 (0,0)	4,7 (1,3)	5.7 (0,4)
Total primary outcome events, n	32	3	13	16
Death, n (%)	11 (11%)	2 (11%)	4 (7,5%)	5 (16%)	0.491
HF hospitalizations, n (%)	21 (20%)	1 (6%)	9 (17,0%)	11 (34%)	0.012

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