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. 2025 Sep;86(3):264-271.
doi: 10.1016/j.jjcc.2025.03.018. Epub 2025 Apr 3.

An evidence-based tool for screening for heart failure with preserved ejection fraction in primary care: The BREATH2 score

Yuki Saito  1 , Nobuyuki Kagiyama  2 , Tomonari Harada  3 , Tomohiro Kaneko  4 , Kazuki Kagami  5 , Taishi Dotare  4 , Naoki Yuasa  3 , Eiichiro Sato  4 , Hidemi Sorimachi  3 , Azusa Murata  4 , Masashi Kawagoshi  6 , Yoichi Nishiya  6 , Atsutaka Yasui  6 , Yasuo Okumura  7 , Tohru Minamino  4 , Hideki Ishii  3 , Masaru Obokata  8
Affiliations
Free article

An evidence-based tool for screening for heart failure with preserved ejection fraction in primary care: The BREATH2 score

Yuki Saito et al. J Cardiol. 2025 Sep.
Free article

Abstract

Background: Heart failure with preserved ejection fraction (HFpEF) remains underdiagnosed in primary care settings, where echocardiography is not available. This study aimed to develop and validate a scoring system that does not include echocardiographic variables for HFpEF screening among patients with shortness of breath.

Methods: A total of 622 consecutive patients referred for exercise stress echocardiography were evaluated (283 HFpEF and 339 controls). Diagnosis of HFpEF was determined by the HFA-PEFF algorithm Steps 2-3.

Results: Multivariable logistic regression analysis identified age ≥65 years, coronary artery disease, elevated natriuretic peptide levels, anemia, cardiomegaly on chest radiography, and left ventricular high-voltage on electrocardiogram as independent predictors of having HFpEF. A weighted score, including the six predictors and atrial fibrillation, was created (BREATH2 score). The BREATH2 score accurately discriminated HFpEF from controls [area under the curve (AUC) 0.84, p < 0.0001], with a superior diagnostic ability to the H2FPEF score. The diagnostic accuracy was confirmed in an external validation cohort (n = 105, AUC 0.78, p < 0.0001) and in patients whose diagnosis was determined by exercise right heart catheterization (n = 79, AUC 0.75, p = 0.0001). The BREATH2 score classified each patient into different risk categories of having HFpEF, ranging from 4 % to 93 %.

Conclusions: The BREATH2 score can be an effective screening tool in primary care settings to help refer patients to a secondary hospital for further evaluation.

Keywords: Exercise stress testing; Heart failure with preserved ejection fraction; Primary care; Risk score; Screening.

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Conflict of interest statement

Declaration of competing interest Dr. Obokata received speaker honoraria from Novartis, Otsuka Pharmaceutical, AstraZeneca, Eli Lilly, and Nippon Boehringer-Ingelheim. Dr. Ishii received lecture fees from AstraZeneca Inc., Bayer Pharmaceutical Co., Ltd., Boehringer Ingelheim Japan, Bristol-Myers Squibb Inc., Daiichi-Sankyo Pharma Inc., MSD K. K., Mitsubishi Tanabe Pharma Co., Ltd., Mochida Pharmaceutical Co., Ltd., Novartis Japan, and Pfizer Japan Inc. Dr. Kagiyama received speaker honoraria from Novartis, Otsuka Pharmaceutical, Eli Lilly, and Nippon Boehringer-Ingelheim, and was affiliated with a department endowed by Paramount Bed. Mr. Kawagoshi, Dr. Nishiya, and Dr. Yasui are employees of Nippon Boehringer Ingelheim. Boehringer Ingelheim was given the opportunity to review the manuscript for medical and scientific accuracy as it relates to Boehringer Ingelheim substances, as well as intellectual property considerations.

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