Comparative Value of HFpEF Scores for Risk Stratification in Patients with Unexplained Dyspnea

In patients with unexplained dyspnea, heart failure with preserved ejection fraction (HFpEF) is a frequent cause. Diagnostic scores estimate HFpEF probability, but their prognostic role and clinical applicability in this population remain uncertain. This study evaluated the association of HFpEF scores with structural remodeling, functional limitation, and clinical outcomes.

This multicenter cohort study included 2,535 patients with unexplained dyspnea who underwent combined cardiopulmonary exercise testing and echocardiography. HFpEF probability was assessed using H₂FPEF, HFA-PEFF, and HFpEF-ABA scores, with patients stratified into risk categories.

Higher scores correlated with adverse ventricular and atrial remodeling, impaired exercise capacity, and higher pulmonary pressures, both at rest and during exercise. Intermediate and high-risk categories for HFA-PEFF, H₂FPEF, and HFpEF-ABA scores showed significantly elevated hazard ratios versus the low-risk group: HFA-PEFF (HR 2.62 95%CI 1.56-4.40, p<0.001 and 5.49 95%CI 2.82-10.67, p=0.005), H₂FPEF (HR 2.74 95%CI 1.35-5.89, p<0.001 and 6.21 95%CI 2.86-13.5, p<0.001), and HFpEF-ABA (HR 1.28 95%CI 0.57-2.86, p=0.549 and 2.50 95%CI 1.02-6.14, p=0.046), all p<0.001. Event rates increased stepwise across score categories, reaching 10 per 100 patient-years in the high-score groups. Score performance differed, particularly in the elderly, women, and those with atrial fibrillation. Incorporating echocardiographic parameters, particularly resting pulmonary pressure, improved HFpEF-ABA prognostic accuracy. In the NT-proBNP subgroup, functional criteria and NT-proBNP remained independent predictors for outcome.

HFpEF diagnostic scores reflect the structural and functional disease burden as well as clinical risk in unexplained dyspnea. These scores are complementary and may enhance risk stratification.