H₂FPEF and HFA-PEFF scores for heart failure risk stratification in hypertrophic cardiomyopathy patients

H₂FPEF and HFA-PEFF scores have demonstrated prognostic value in heart failure (HF) with preserved ejection fraction. This study aimed to explore the value of the H₂FPEF and HFA-PEFF scores for HF risk stratification in patients with hypertrophic cardiomyopathy (HCM).

In this cohort study, 1068 HCM patients were included. Then the H₂FPEF and HFA-PEFF scores were calculated to categorize patients into low, intermediate, and high score groups. The primary endpoint was a composite of the first HF hospitalization and all-cause death. 594 (55.6%) patients were classified discordantly. After a follow-up period of 3.1 ± 2.1 years, 85 (8.0%) patients were admitted for HF for the first time, and 62 (5.8%) patients died. Rates of first HF hospitalization and all-cause death per 1000 person-years for the low, intermediate, and high H₂FPEF score groups were 25.0 (95% confidence interval [CI]: 14.5-35.4), 52.0 (95% CI: 41.6-62.3), and 148.1 (95% CI: 77.7-218.5), respectively. For the low-intermediate and high HFA-PEFF score groups, rates were 19.3 (95% CI: 11.6-27.0) and 69.3 (95% CI: 56.4-82.1), respectively. Intermediate H₂FPEF score (hazard ratio [HR]: 1.820, 95% CI: 1.135-2.919; P = 0.013), high H₂FPEF score (HR: 3.464, 95% CI: 1.774-6.765; P < 0.001), and high HFA-PEFF score (HR: 2.414, 95% CI: 1.501-3.882; P < 0.001) were each independently associated with an increased risk of the primary endpoint. Intermediate-high H₂FPEF score demonstrated an equal risk for the primary endpoint compared to the high HFA-PEFF score (HR: 0.826, 95% CI: 0.636-1.072; P > 0.05). Obesity (HR: 1.958, 95% CI: 1.140-3.363; P = 0.015), atrial fibrillation (HR: 1.686, 95% CI: 1.071-2.654; P = 0.024), pulmonary hypertension (HR: 1.613, 95% CI: 1.032-2.521; P = 0.036) of the H₂FPEF score, and the morphological major criterion (HR: 1.601, 95% CI: 1.084-2.364; P = 0.018) and functional major criterion (HR: 2.340, 95% CI: 1.442-3.797; P < 0.001) of the HFA-PEFF score were independent predictors of the primary endpoint. A new algorithm was constructed using the independent predictors from both scores, with the functional major criterion weighted as 2 points and the others as 1 point. The H₂FPEF score, HFA-PEFF score, and the new algorithm demonstrated C-indices of 0.594, 0.651, and 0.681, respectively.

There is discordance in the classification of patients with HCM using the H₂FPEF and HFA-PEFF scores. Both scores demonstrated prognostic value in risk stratification for HF hospitalization and all-cause death in HCM patients. Future studies should develop and validate a new algorithm integrating both scores.