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Validity of Diagnostic Scores in HFpEF and Symptomatic AF
Quick Takes
- In a cohort of patients with AF and HFpEF confirmed with invasive hemodynamics, HFA-PEFF and H2FPEF scores had modest accuracy at best in HFpEF diagnosis.
- Young, male and obese patients with HFpEF were more likely to be classified as low to intermediate risk for HFpEF with HFA-PEFF score.
Study Questions:
What is the utility and validity of HFA-PEFF and H2FPEF scores for diagnosis of heart failure with preserved ejection fraction (HFpEF) in patients with symptomatic atrial fibrillation (AF)?
Methods:
This was a prospective cohort study at the University of Adelaide, Australia. Adults with symptomatic or persistent AF with a planned AF ablation were included. Both HFA-PEFF (Heart Failure Association Pre-test assessment, Echocardiography and natriuretic peptide, Functional testing, Final etiology) and H2FPEF scores were calculated 4 weeks prior to planned ablation and correlated with invasive hemodynamics performed at the time of ablation after transseptal puncture.
Results:
This study included 120 patients with AF. Overall, 73% of patients had HFpEF based on a mean left atrial (LA) pressure >15 mm Hg or increase in LA pressure with intravenous saline. Based on HFA-PEFF score, 32% of patients were classified as high probability HFpEF and 68% had low or intermediate probability. A high probability HFA-PEFF score had a specificity of 91% with poor sensitivity at 40%, a positive predictive value of 92%, and a negative predictive value of 35%. With application of the H2FPEF score, 60% of patients were classified as high probability of HFpEF and the remaining 40% were classified as intermediate probability. A high probability H2FPEF score had a higher sensitivity of 69% but with poorer specificity of 66% and a positive predictive value of 85% and negative predictive value of 43%. There was no statistically significant difference between the two scores based on receiver operating curves. While the HFA-PEFF score underestimated HFpEF diagnosis in young, male and obese patients, H2FPEF score omitted patients with normal resting hemodynamics but with abnormal hemodynamics with saline infusion.
Conclusions:
In a prospective cohort of AF patients, compared with invasive hemodynamics, HFA-PEFF and H2FPEF scores had modest diagnostic accuracy for HFpEF diagnosis.
Perspective:
AF is widely prevalent in patients with HFpEF. However, diagnosing HFpEF in patients with AF remains challenging due to similar signs and symptoms. More recently, both HFA-PEFF and H2FPEF scores have emerged as useful diagnostic tools for HFpEF. However, these scores have not been validated in patients with AF and HFpEF. This study shows that compared against the gold standard of invasive hemodynamics for HFpEF diagnosis, HFA-PEFF had a high specificity but poor sensitivity and H2FPEF score had a higher sensitivity with poor specificity. Both of these scores only had modest diagnostic accuracy. These findings suggest that a large proportion of AF patients with HFpEF would be considered intermediate probability for HFpEF with both of these scores with patients needing invasive hemodynamics for confirmation of diagnosis. Important clinical groups that were underdiagnosed with these scores included young, male and obese patients. A noteworthy strength of this study includes direct LA pressure measurement in all participants as opposed to measurement of surrogate wedge pressures.
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias, Heart Failure and Cardiomyopathies
Keywords: Atrial Fibrillation, Heart Failure, Preserved Ejection Fraction
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