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Evidence-Based Approach to Help Guide Diagnosis of HFpEF
Study Questions:
Is it possible to develop noninvasive diagnostic criteria that could be used to estimate the likelihood that heart failure with preserved ejection fraction (HFpEF) is present among patients with unexplained dyspnea?
Methods:
Consecutive patients with unexplained dyspnea referred for invasive hemodynamic exercise testing were retrospectively evaluated. The diagnosis of HFpEF or noncardiac dyspnea (control) was ascertained by invasive hemodynamic exercise testing. Logistic regression was performed to evaluate the ability of clinical findings to discriminate HFpEF from controls. A scoring system was developed and then validated in a separate test cohort.
Results:
The derivation cohort included 414 consecutive patients (267 patients with HFpEF and 147 without; HFpEF prevalence 64%). The test cohort included 100 consecutive patients (61 with HFpEF; prevalence 61%). Obesity, atrial fibrillation, age >60 years, treatment with ≥2 antihypertensive agents, echocardiographic E/e’ ratio >9, and echocardiographic pulmonary artery systolic pressure >35 mm Hg were selected as the final set of predictive variables. A weighted score based on these six variables was used to create a composite score (H2FPEF score) ranging from 0 to 9. The odds of HFpEF doubled for each 1-unit score increase (odds ratio, 1.98; 95% confidence interval [CI], 1.74-2.30; p < 0.0001), with an area under the curve of 0.841 (p < 0.0001). The H2FPEF score was superior to a currently used algorithm based on expert consensus (increase in area under the curve of 0.169; 95% CI, 0.120-0.217; p < 0.0001). Performance in the independent test cohort was maintained (area under the curve, 0.886; p < 0.0001).
Conclusions:
The authors concluded that the H2FPEF score, which relies on simple clinical characteristics and echocardiography, enables discrimination of HFpEF from noncardiac causes of dyspnea and can assist in determination of the need for further diagnostic testing in the evaluation of patients with unexplained exertional dyspnea.
Perspective:
Patients with decompensated HFpEF typically have evidence of volume overload and overt congestion on physical examination. Although HFpEF can present as dyspnea among euvolemic patients, many other cardiac and noncardiac conditions similarly can present with dyspnea. This impressive study used invasive hemodynamics with exercise to define HFpEF among patients with dyspnea, but without overt volume overload. A ‘H2PEF’ score (Heavy [body mass index >30 kg/m2, 1 point], Hypertension [≥2 antihypertensive agents, 1 point], atrial Fibrillation [3 points], Pulmonary hypertension [right ventricular systolic pressure >35 mm Hg, 1 point], Elder [age >60 years, 1 point], Filling pressure [Doppler E/e’ >9, 1 point]) was clinically useful in helping discriminate HFpEF from other causes of dyspnea. Because clinical HFpEF correlates poorly with isolated echo/Doppler indices of LV diastology, this tool could prove to be clinically very helpful.
Keywords: Antihypertensive Agents, Atrial Fibrillation, Blood Pressure, Body Mass Index, Diagnostic Imaging, Dyspnea, Echocardiography, Exercise Test, Heart Failure, Heart Failure, Diastolic, Hypertension, Hypertension, Pulmonary, Obesity, Stroke Volume
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