Assessing the Risk of Heart Failure With Preserved Ejection Fraction in Individuals With Exertional Dyspnea

CLINICAL QUESTION

How can patients with exertional dyspnea who are at risk of heart failure with preserved ejection fraction (HFpEF) be identified?

EVIDENCE SUMMARY

In the United States, heart failure affects 27 per 1,000 Medicare beneficiaries and was associated with more than 300,000 deaths in 2014 and 1.2 million hospitalizations in 2017.¹ The American Heart Association (AHA), American College of Cardiology (ACC), and the Heart Failure Society of America (HFSA) define heart failure as a clinical syndrome caused by structural or functional challenges in the way blood fills or is ejected from the ventricles. HFpEF describes heart failure with a left ventricular ejection fraction of 50% or greater.¹

Recent advances have led to effective treatments for HFpEF. Sodium-glucose cotransporter-2 (SGLT-2) inhibitors have been shown to reduce the composite of cardiovascular mortality and hospitalization for heart failure in those with HFpEF.² Other studies have shown that glucagon-like peptide-1 receptor agonists may help decrease heart failure exacerbations and improve quality of life, as measured by the Kansas City Cardiomyopathy Questionnaire.³ AHA/ACC/HFSA guidelines recommend blood pressure and atrial fibrillation control and use of SGLT-2 inhibitors for individuals with HFpEF. They also recommend that mineralocorticoid receptor antagonists, angiotensin receptor blockers, and angiotensin receptor blocker–neprilysin inhibitors should be considered in patients with HFpEF.¹

With availability of effective treatments, a tool that helps identify patients with exertional dyspnea who have HFpEF would be useful for guiding evaluation and management. An early clinical prediction rule, the H₂FPEF score, was developed from a cohort of 414 patients, 267 of whom had HFpEF, determined by elevated pulmonary capillary wedge pressures at rest or during exercise in the setting of an...