The H2FPEF and HFA-PEFF algorithms for predicting exercise intolerance and abnormal hemodynamics in heart failure with preserved ejection fraction

Abstract

Exercise intolerance is a primary manifestation in patients with heart failure with preserved ejection fraction (HFpEF) and is associated with abnormal hemodynamics and a poor quality of life. Two multiparametric scoring systems have been proposed to diagnose HFpEF. This study sought to determine the performance of the H₂FPEF and HFA-PEFF scores for predicting exercise capacity and echocardiographic findings of intracardiac pressures during exercise in subjects with dyspnea on exertion referred for bicycle stress echocardiography. In a subset, simultaneous expired gas analysis was performed to measure the peak oxygen consumption (VO₂). Patients with HFpEF (n = 83) and controls without HF (n = 104) were enrolled. The H₂FPEF score was obtainable for all patients while the HFA-PEFF score could not be calculated for 23 patients (feasibility 88%). Both H₂FPEF and HFA-PEFF scores correlated with a higher E/e' ratio (r = 0.49 and r = 0.46), lower systolic tricuspid annular velocity (r = - 0.44 and = - 0.24), and lower cardiac output (r = - 0.28 and r = - 0.24) during peak exercise. Peak VO₂ and exercise duration decreased with an increase in H₂FPEF scores (r = - 0.40 and r = - 0.32). The H₂FPEF score predicted a reduced aerobic capacity (AUC 0.71, p = 0.0005), but the HFA-PEFF score did not (p = 0.07). These data provide insights into the role of the H₂FPEF and HFA-PEFF scores for predicting exercise intolerance and abnormal hemodynamics in patients presenting with exertional dyspnea.

Figure 1

Distribution of H₂FPEF and HFA-PEFF scores among all participants. The H₂FPEF score was more likely to classify subjects into a low or intermediate probability while the HFA-PEFF score categorized them as a high probability.

Figure 2

Correlations between echocardiographic measures and exercise capacity. Decreases in mitral annular e′ velocity and cardiac output (CO) during exercise were moderately correlated with lower peak oxygen consumption (VO₂). HFpEF, heart failure with preserved ejection fraction (HFpEF).

Figure 3

Correlations between HFpEF diagnostic algorithms and exercise capacity. The H₂FPEF score was correlated with peak VO₂, but the HFA-PEFF score was not. Abbreviations as in Fig. 2.

Figure 4

Receiver-operating characteristic curves of the H₂FPEF and HFA-PEFF scores to predict impaired exercise capacity. AUC, area under the curve.

Figure 5

Peak oxygen consumption according to the HFA-PEFF domain scores. (A) Peak VO₂ did not differ among the HFA-PEFF functional domain scores. (B) Peak VO₂ was similar among the HFA-PEFF morphological domain scores. (C) In contrast, patients with a natriuretic peptide domain of 2 points displayed lower peak VO₂ compared to the other groups. *p < 0.05 vs. 0 point, #p < 0.05 vs. 1 point. Abbreviations as in Fig. 2.