Heart failure is a complex condition where the heart cannot pump enough blood to meet the body’s needs. One common form is Heart Failure with Preserved Ejection Fraction (HFpEF), a diagnosis that can be difficult to establish because its symptoms often mimic other conditions. Ejection fraction is the percentage of blood leaving the heart with each contraction, and in HFpEF, this value remains within a normal range. Cardiologists developed standardized tools, known as HFpEF scores, to help identify the likelihood of this specific condition. These scores integrate multiple pieces of patient data to provide an objective probability assessment.
Understanding Heart Failure with Preserved Ejection Fraction (HFpEF)
Heart failure with preserved ejection fraction (HFpEF) is a condition where the heart’s pumping action is preserved. The left ventricle still ejects a healthy percentage of blood (typically 50% or more) with every beat. The issue is not a failure to squeeze, but a failure to relax and fill properly between beats, known as diastolic dysfunction. This stiffness limits the amount of blood the ventricle can take in.
The heart muscle may thicken and become rigid over time, often driven by long-term high blood pressure, diabetes, and obesity. This impaired filling means that even though the heart pumps efficiently, the overall volume of blood available to the body is restricted, leading to symptoms. This mechanism contrasts with Heart Failure with Reduced Ejection Fraction (HFrEF), where the heart muscle is weakened and cannot contract forcefully enough, resulting in an ejection fraction of 40% or lower. HFpEF is estimated to account for about half of all heart failure cases, with its prevalence increasing due to a rise in associated risk factors.
The Need for Diagnostic Scoring Tools
Diagnosing HFpEF is challenging because classic symptoms like shortness of breath and fatigue are not unique to heart failure. These complaints frequently overlap with other common conditions, including obesity, anemia, or various lung diseases. Furthermore, traditional diagnostic tests, particularly ejection fraction measurement, often return a normal result, leading to misdiagnosis or delayed treatment.
The non-specific nature of symptoms and the preserved pumping function mean that a single, definitive test for HFpEF does not exist. This makes it difficult for clinicians to reach a confident diagnosis based only on initial presentation and standard tests. Structured, objective scoring systems were developed to address this diagnostic uncertainty. These algorithms integrate a patient’s clinical history, physical exam findings, and results from basic tests into a single probability score.
The scores help combine multiple, subtle data points that might otherwise be evaluated in isolation. By creating a standardized, weighted assessment, these tools provide an objective estimate of the pre-test probability of HFpEF. This structured approach ensures that patients most likely to have the condition are moved forward for the specialized, advanced testing required for confirmation.
Key Components of the HFpEF Scoring Systems
Cardiologists frequently use two prominent scoring systems to estimate the likelihood of HFpEF: the H2FPEF score and the HFA-PEFF score. These scores function as checklists, assigning points based on various patient characteristics and test results.
The H2FPEF Score
The H2FPEF score incorporates clinical factors such as a high Body Mass Index (BMI), a history of atrial fibrillation, and age (typically over 60 years). It also considers whether the patient is being treated with two or more medications for high blood pressure. Echocardiographic components focus on measurements that suggest elevated filling pressures in the heart, such as a high E/e’ ratio or signs of pulmonary hypertension.
The HFA-PEFF Score
The HFA-PEFF score, developed by the Heart Failure Association of the European Society of Cardiology, takes a complex, multi-step approach. It categorizes criteria into three main domains: functional, morphological, and biomarker. Functional criteria include detailed echocardiographic measurements of the heart’s relaxation ability, such as the E/e’ ratio and tricuspid regurgitation velocity.
Morphological components assess structural changes in the heart, such as enlargement of the left atrium or thickening of the left ventricular wall. The biomarker domain integrates levels of natriuretic peptides (like NT-proBNP) in the blood, which are hormones released when the heart muscle is stretched. Both scoring systems weigh these criteria, typically awarding points for severe or specific findings, to generate a total probability score.
Interpreting the Score and Next Steps
The numerical result from an HFpEF score places the patient into one of three categories: low, intermediate, or high probability of having the condition. A low score (0 to 1 point on either scale) suggests that HFpEF is highly unlikely and the clinician should look for other causes of the patient’s symptoms. Conversely, a high score (typically 6 to 9 points for H2FPEF or 5 or more points for HFA-PEFF) is considered highly consistent with a diagnosis of HFpEF.
The score itself is a screening tool, not a final, definitive diagnosis; it guides the need for further investigation. Patients who fall into the intermediate score range (usually 2 to 5 points on the H2FPEF scale or 2 to 4 points on the HFA-PEFF scale) require specialized testing to resolve the diagnostic uncertainty. A significant portion of patients fall into this intermediate group.
Advanced Diagnostic Testing
The next steps for patients with an intermediate score often involve advanced functional testing, such as a diastolic stress echocardiogram. This test involves imaging the heart while the patient exercises, which can unmask the filling problem that is not apparent at rest. If non-invasive tests remain inconclusive, the final step may be an invasive hemodynamic assessment using a cardiac catheterization. This procedure directly measures the pressures inside the heart chambers, with elevated pressures during rest or exercise serving as the gold standard for confirming the diagnosis of HFpEF.