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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. The score was validated with a cohort of 100 additional patients and had an area under the curve (AUC) of 0.886 (values of more than 0.8 are generally considered good).4 The European Society of Cardiology released an alternative diagnostic pathway for HFpEF called the Heart Failure Association-Pretest assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology (HFA-PEFF) score, which assigns points for different functional and structural findings on echocardiography and varying levels of elevated brain natriuretic peptide (BNP; different cutoffs for BNP are used based on whether a patient is in sinus rhythm or atrial fibrillation).5 This score was validated in two cohorts of 270 and 459 patients, with an AUC of 0.90.6 The H2FPEF and HFA-PEFF scores may require more information than is available during an ambulatory encounter for exertional dyspnea in a setting without immediate access to echocardiography or BNP testing. AARON SAGUIL, MD, MPH; PETRA TOWNSEND, MD; and MARK H. EBELL, MD, MS 1 Heidenreich, PA; Bozkurt, B; Aguilar, D et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.
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.
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.
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 ejection fraction of 50% or greater. The factors used in the H2FPEF score include body mass index, use of antihypertensive medication, atrial fibrillation, pulmonary hypertension, age, and filling pressures shown on echocardiography. The score was validated with a cohort of 100 additional patients and had an area under the curve (AUC) of 0.886 (values of more than 0.8 are generally considered good).
The European Society of Cardiology released an alternative diagnostic pathway for HFpEF called the Heart Failure Association-Pretest assessment, Echocardiography and natriuretic peptide, Functional testing, Final aetiology (HFA-PEFF) score, which assigns points for different functional and structural findings on echocardiography and varying levels of elevated brain natriuretic peptide (BNP; different cutoffs for BNP are used based on whether a patient is in sinus rhythm or atrial fibrillation).
The H2FPEF and HFA-PEFF scores may require more information than is available during an ambulatory encounter for exertional dyspnea in a setting without immediate access to echocardiography or BNP testing. To address the need for a screening tool based on readily available information that can guide the decision for further testing, the HFpEF-ABA tool was developed.
The HFpEF-ABA score combines age, body mass index, and history of atrial fibrillation (present = 1; absent = 0) and yields a probability for HFpEF with an AUC of 0.84 (95% CI, 0.80–0.88) in the derivation cohort and 0.81 (95% CI, 0.78–0.85) in the primary validation cohort (
Sample Scenarios and Application of the HFpEF-ABA Equation for Estimating the Probability of Heart Failure With Preserved Ejection Fraction
| Age (years) | Body mass index (kg/m2) | |||||
|---|---|---|---|---|---|---|
| 18 | 22 | 26 | 30 | 34 | 38 | |
| History of atrial fibrillation | ||||||
| 40 | 31% | 43% | 57% | 69% | 79% | 87% |
| 45 | 38% | 51% | 64% | 75% | 84% | 90% |
| 50 | 45% | 59% | 71% | 81% | 88% | 92% |
| 55 | 53% | 66% | 77% | 85% | 91% | 94% |
| 60 | 61% | 73% | 82% | 89% | 93% | 96% |
| 65 | 68% | 78% | 86% | 91% | 95% | 97% |
| 70 | 74% | 83% | 89% | 94% | 96% | 98% |
| 75 | 80% | 87% | 92% | 95% | 97% | 98% |
| 80 | 84% | 90% | 94% | 96% | 98% | 99% |
No history of atrial fibrillation | ||||||
| 40 | 5% | 9% | 14% | 23% | 33% | 46% |
| 45 | 7% | 12% | 19% | 28% | 41% | 54% |
| 50 | 10% | 16% | 24% | 35% | 48% | 62% |
| 55 | 13% | 20% | 30% | 43% | 56% | 69% |
| 60 | 17% | 26% | 37% | 50% | 64% | 75% |
| 65 | 21% | 32% | 45% | 58% | 70% | 80% |
| 70 | 27% | 39% | 52% | 65% | 76% | 85% |
| 75 | 34% | 47% | 60% | 72% | 82% | 88% |
| 80 | 41% | 55% | 67% | 78% | 86% | 91% |
BMI = body mass index; HFpEF-ABA = heart failure with preserved ejection fraction-age, body mass index, atrial fibrillation.
Note: HFpEF-ABA equation = −7.788751 + 0.062564(age) + 0.135149(BMI) + 2.040806(history of atrial fibrillation [1 if present, 0 if not present]).
Information from reference
APPLYING THE EVIDENCE
A 57-year-old patient with a history of atrial fibrillation presents to your office with exertional dyspnea. He is 6 ft (182.88 cm) tall and weighs 317 lb (143.79 kg); his body mass index is 43 kg/m2. You use the HFpEF-ABA tool to calculate his probability of HFpEF, and it is 97%. You arrange for additional testing with echocardiography for further evaluation.
Editor’s Note: Dr. Ebell is deputy editor for evidence-based medicine for AFP and cofounder and editor-in-chief of Essential Evidence Plus, published by Wiley-Blackwell. Dr. Saguil is an assistant medical editor for AFP.
AARON SAGUIL, MD, MPH, FAAFP, and PETRA TOWNSEND, MD, FAAFP, University of Florida, Gainesville
MARK EBELL, MD, MS, Michigan State University, East Lansing
Author disclosure: No relevant financial relationships.
AARON SAGUIL, MD, MPH; PETRA TOWNSEND, MD; and MARK H. EBELL, MD, MS
1 Heidenreich, PA; Bozkurt, B; Aguilar, D
2 Karakasis, P; Pamporis, K; Stachteas, P
3 Packer, M; Zile, MR; Kramer, CM
4 Reddy, YNV; Carter, RE; Obokata, M
5 Pieske, B; Tschöpe, C; de Boer, RA
6 Barandiarán Aizpurua, A; Sanders-van Wijk, S; Brunner-La Rocca, HP
7 Reddy, YNV; Carter, RE; Sundaram, V
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