What is the clinical significance and calculation of the H2FPEF (Heart Failure with preserved Ejection Fraction) score in a patient with a history of hypertension (High Blood Pressure), diabetes, and impaired renal function (Chronic Kidney Disease)?

H2FPEF Score: Clinical Significance and Calculation

The H2FPEF score is a validated 0-9 point diagnostic tool that doubles the odds of HFpEF with each 1-point increase, with scores ≥6 indicating high likelihood of HFpEF, scores <2 indicating low likelihood, and scores 2-5 requiring further hemodynamic testing to confirm the diagnosis. 1

Score Calculation

The H2FPEF score integrates six weighted variables to create a composite score ranging from 0 to 9 1:

Components and Point Values:

• H - Heavy (obesity): BMI >30 kg/m² = 2 points 1
• H - Hypertension: Treatment with ≥2 antihypertensive medications = 1 point 1
• F - Atrial Fibrillation: Paroxysmal or persistent = 3 points 1
• P - Pulmonary hypertension: Echocardiographic PA systolic pressure >35 mm Hg = 1 point 1
• E - Elder: Age >60 years = 1 point 1
• F - Filling pressure: Echocardiographic E/e' ratio >9 = 1 point 1

Clinical Significance and Interpretation

Diagnostic Performance:

The score demonstrated excellent discrimination with a c-statistic of 0.841 (95% CI: 1.74-2.30; P<0.0001) 1. The odds of HFpEF doubled for each 1-unit score increase (odds ratio 1.98) 1.

Risk Stratification:

• Low likelihood (0-1 points): HFpEF unlikely; consider alternative diagnoses for dyspnea 1
• Intermediate likelihood (2-5 points): Further evaluation required with exercise echocardiogram or cardiac catheterization to confirm or exclude HFpEF 1
• High likelihood (≥6 points): HFpEF highly probable; proceed with HFpEF-directed therapy 1

Prognostic Value:

Beyond diagnosis, the H2FPEF score predicts cardiovascular outcomes in HFpEF patients 2. Higher scores correlate with increased risk of cardiovascular/cerebrovascular events and HF-related hospitalizations 2. The score independently predicts cardiovascular events (HR 1.179 per point; 95% CI 1.066-1.305; P=0.001) and HF-related events (HR 1.288 per point; 95% CI 1.134-1.463; P=0.001) 2. A cutoff score of 5.5 optimally identifies patients at risk for adverse events 2.

The score also reflects left atrial function and diastolic dysfunction severity, with higher scores associated with worse LA strain, larger LA size, higher E/e' ratios, and elevated tricuspid regurgitation velocities 3.

Application in Your Patient

For a patient with hypertension, diabetes, and chronic kidney disease, calculate the H2FPEF score as follows:

1. Assess obesity: Measure BMI; if >30 kg/m², add 2 points 1
2. Count antihypertensive medications: If on ≥2 agents, add 1 point 1
3. Check for atrial fibrillation: Review ECG/rhythm monitoring; if present, add 3 points 1
4. Obtain echocardiogram:
   • Measure PA systolic pressure; if >35 mm Hg, add 1 point 1
   • Calculate E/e' ratio; if >9, add 1 point 1
5. Confirm age: If >60 years, add 1 point 1

Critical Caveats

The H2FPEF score requires echocardiographic data (E/e' ratio and PA pressure), which may not be immediately available 1. If echocardiography is unavailable, consider the simpler HFpEF-ABA score (age, BMI, atrial fibrillation only) for initial screening, which demonstrated AUC of 0.839 in validation 4.

A low H2FPEF score should not exclude HFpEF diagnosis when clinical suspicion is high based on symptoms, signs, and elevated natriuretic peptides 1. The pretest probability based on classic risk factors (older age, obesity, diabetes, hypertension, atrial fibrillation) guides the diagnostic utility of the scoring system 1.

Chronic kidney disease is a powerful risk factor for adverse outcomes in HFpEF but is not included in the H2FPEF score calculation 5. Your patient's renal impairment increases their risk for HF hospitalization and death independent of the H2FPEF score 5.

Diabetes is not directly scored in H2FPEF but contributes to worse outcomes in HFpEF 1. Patients with both HFpEF and diabetes have up to 50% higher hospitalization risk and worse quality of life compared to HFpEF alone 1.

When to Pursue Further Testing

If the H2FPEF score falls between 2-5 points, do not stop at the score alone 1. Proceed with exercise stress echocardiography to assess diastolic parameters during exertion, or perform invasive hemodynamic assessment measuring pulmonary capillary wedge pressure, LV end-diastolic pressure, PA pressures, stroke volume, and cardiac output at rest or with exercise 1.

Many clinicians facing intermediate scores may reasonably initiate a therapeutic trial of guideline-directed medical therapy (diuretics plus SGLT2 inhibitor) and assess for symptomatic improvement rather than pursuing invasive testing 1, 6. This pragmatic approach is acceptable when diastolic stress testing or catheterization is not readily available 1.