Application of Diagnostic Algorithms for Heart Failure With Preserved Ejection Fraction to the Community

Abstract

Objectives: This study sought to describe characteristics and risk of adverse outcomes associated with the H₂FPEF and HFA-PEFF scores among participants in the community with unexplained dyspnea.

Background: Diagnosing heart failure with preserved ejection fraction (HFpEF) can be challenging. The H₂FPEF and HFA-PEFF scores have recently been developed to estimate the likelihood that HFpEF is present among patients with unexplained dyspnea.

Methods: The study included 4,892 ARIC (Atherosclerosis Risk In Communities) study participants 67 to 90 years of age at visit 5 (2011 to 2013) without other common cardiopulmonary causes of dyspnea. Participants were categorized as asymptomatic (76.6%), having known HFpEF (10.3%), and having tertiles of each score among those with ≥moderate, self-reported dyspnea (13.1%). The primary outcome was heart failure (HF) hospitalization or death.

Results: Mean age was 75 ± 5 years, 58% were women, and 22% were black. After a mean follow-up of 5.3 ± 1.2 years, rates of HF hospitalization or death per 1,000 person-years for asymptomatic and known HFpEF were 20.7 (95% confidence interval [CI]: 18.9 to 22.7) and 71.6 (95% CI: 61.6 to 83.3), respectively. Among 641 participants with unexplained dyspnea, rates were 27.7 (95% CI: 18.2 to 42.1), 44.9 (95% CI: 34.9 to 57.7), and 47.3 (95% CI: 36.5 to 61.3) (tertiles of H₂FPEF score) and 31.8 (95% CI: 20.3 to 49.9), 32.4 (95% CI: 23.4 to 44.9), and 54.3 (95% CI: 43.8 to 67.3) (tertiles of HFA-PEFF score). Participants with unexplained dyspnea and scores above the diagnostic threshold suggested for each algorithm, H₂FPEF score ≥6 and HFA-PEFF score ≥5, had equivalent risk of HF hospitalization or death compared with known HFpEF. Among those with unexplained dyspnea, 28% had "discordant" findings (only high risk by 1 algorithm), while 4% were high risk by both.

Conclusions: Participants with unexplained dyspnea and higher H₂FPEF or HFA-PEFF scores face substantial risks of HF hospitalization or death. A significant fraction of patients are classified discordantly by using both algorithms.

Keywords: H(2)FPEF score; HFA-PEFF score; diagnosis; heart failure with preserved ejection fraction; hospitalization; mortality; prognosis; risk scores.

Figure 1:. Histogram of Diagnostic Scores by Symptoms

Percent of participants at each H₂FPEF (left) and HFA-PEFF (right) score shown for asymptomatic participants, participants with unexplained dyspnea, and established HFpEF participants. A reference line is drawn in the histograms of participants with unexplained dyspnea to indicate the cutoff above which “high risk” for HFpEF has been suggested. HFpEF, heart failure with preserved ejection fraction.

Figure 2:. Venn Diagram of Participants with Unexplained Dyspnea by Diagnostic Scores

Of the 641 participants with unexplained dyspnea, 435 participants were non-high risk by both scores (H₂FPEF<6 and HFA-PEFF<5). By the H₂FPEF score, 69 were “high risk” (≥6) and by the HFA-PEFF score, 164 were “high risk” (≥5). 27 participants were “high risk” by both scores.

Figure 3:. Cumulative Incidence Curves for Adverse Events by H₂FPEF Score.

Cumulative incidence curves for each of the study outcomes by symptoms (unexplained dyspnea) and H₂FPEF score at Visit 5: 1) asymptomatic; 2) symptomatic and H₂FPEF score 1–2; 3) symptomatic and H₂FPEF score 3–4; 4) symptomatic and H₂FPEF-score ≥5; and 5) known HFpEF. P-value shown for log-rank test.

Figure 4:. Cumulative Incidence Curves for Adverse Events by HFA-PEFF Score.

Cumulative incidence curves for each of the study outcomes by symptoms (unexplained dyspnea) and HFA-PEFF score at Visit 5: 1) asymptomatic; 2) symptomatic and HFA-PEFF score 0–2; 3) symptomatic and HFA-PEFF score 3; 4) symptomatic and HFA-PEFF score ≥4; and 5) known HFpEF. P-value shown for log-rank test.

Figure 5 (CENTRAL ILLUSTRATION). Incidence Rates for Heart Failure Hospitalization or Death by H₂FPEF and HFA-PEFF Scores.

Incidence rates by H₂FPEF and HFA-PEFF scores for the combined outcome for asymptomatic participants, participants with unexplained dyspnea without heart failure, and known HFpEF. HFpEF, heart failure with preserved ejection fraction.