Prognostic Significance of the Modified H2FPEF Score in Patients with Severe Primary Mitral Regurgitation

Severe mitral regurgitation (MR) has been associated with significant morbidity and mortality, necessitating effective risk stratification. The H2FPEF score has demonstrated prognostic value in other cardiac disorders. This study evaluates the prognostic utility of a modified version of the H2FPEF score for severe MR with preserved ejection fraction.

Patients from a tertiary cardiovascular referral center with consecutive index echocardiographic diagnoses of severe MR were included. We excluded patients with secondary MR, reduced LVEF (<50%) and/or missing information for modified H2FPEF score calculation. A modified H2FPEF score was utilized in view of differing obesity cutoffs in our Asian population (BMI > 25 kg/m²) as opposed to the original cutoff (BMI > 30 kg/m²). Patients were stratified based on the modified score into low (0-1), intermediate (2-5), and high (6-9) groups. The primary endpoint, a composite of all-cause mortality and first heart failure hospitalization (HFH), was analyzed using multivariate Cox regression. A total of 388 patients (low 57 [14.7%]; intermediate 218 [56.2%]; high 113 [29.1%] modified H2FPEF score) were included with a median follow-up duration of 4.53 years (interquartile range 2.61 to 6.60). Patients with a high modified H2FPEF score were older, more likely to have hyperlipidemia, diabetes, end-stage renal disease, higher NYHA class, and lower LVEF. Malay ethnicity, hyperlipidemia, diabetes, end-stage renal disease and a higher indexed left atrial diameter were independently associated with greater modified H2FPEF score. High and intermediate modified H2FPEF scores were associated with the primary endpoint (HR 9.17, 95% CI 2.15-39.1 and 6.71, 95% CI 1.62-27.9 respectively) versus low scores. However, a Fine-Gray regression showed no difference in subdistribution hazards of first HFH between high and intermediate scores.

The modified H2FPEF score may facilitate risk stratification for all-cause mortality and first HFH in patients with severe primary MR and preserved ejection fraction.