After 18 years of the classic pathophysiological characterization of what we currently call “heart failure (HF) with preserved ejection fraction (HFpEF)”, its diagnostic criteria remain questionable and evolving.¹ Even with historically different diagnostic criteria, establishing its prevalence and assessing its prognosis is an increasing challenge in primary care. In 2016, the European Society of Cardiology (ESC) established the following as criteria for HFpEF: the presence of signs and or symptoms of HF; left ventricle ejection fraction (LVEF) greater than or equal to 50%; elevation of natriuretic peptides; and the presence of cardiac structural or functional alteration.² In general, primary care physicians find it difficult to deal with patients with multiple comorbidities, signs and symptoms of HF and preserved LVEF and, in such cases, easily accessible tools that assist the physician in diagnosis and prognosis can be extremely useful. Recently, a scoring system called the H₂FPEF score³ was proposed to estimate the diagnostic probability of HFpEF in patients assisted in a specialized HF unit. However, the prognostic utility of this score remains unknown in primary care patients. The aim of the present study is to apply the H₂FPEF score to patients in primary care and to verify its predictive power of outcomes.

Among the 402 subjects (mean age = 60.2±10.0 years, 71% women) involved in the study, HFpEF was diagnosed in 58 subjects (14.4%) and these patients with HFpEF had a score H₂FPEF 2 (1-4). All the parameters used in the score model were significantly different between patients with and without HFpEF, except for body mass index (BMI) and pulmonary artery systolic pressure (PASP). The anthropometric, clinical and laboratory characteristics are shown in Table 1. Table 2 shows the main echocardiographic parameters.

Among patients with a H₂FPEF score ≥ 4, 30% had HFpEF and among patients with a score ≤ 4, 12% presented HFpEF. BNP values were higher in patients with HFpEF compared to those without HFpEF, regardless of the score obtained in the H₂FPEF. In patients with HFpEF and score ≤3, a lower outcome rate (21%) was observed compared to patients with HFpEF and a score ≥4 (53%), showing that the higher the H₂FPEF score, the greater the risk of death and/or hospitalization due to cardiovascular disease.

After a 5-year follow-up, 42 (10.4%) composite outcomes were observed, with 21% in patients with HFpEF and a score ≤4, and 53% in patients with HFpEF and a score ≥4. In patients without HFpEF, the rate of outcomes was 7% in patients with a score ≤4 and 6% in patients with a score ≥4 (Table 3).

This study evaluates the H₂FPEF score in patients in primary care. Our data show that patients with HFpEF and a H₂FPEF score ≥4 are at increased risk of death from any cause or hospitalization for cardiovascular disease.

A secondary analysis of the TOPCAT study evaluated the association between the probability of HFpEF by the H₂FPEF score system and the primary endpoint composed of cardiovascular death, aborted cardiac arrest or HF hospitalization in patients with HFpEF using spironolactone or placebo. The high probability of HFpEF according to the H₂FPEF score was associated with worsening renal function, elevated natriuretic peptide values, increased left ventricle mass and left atrium (LA) size⁶.

When comparing the patients with and without HFpEF according to the H₂FPEF score, we observed that in those with a score ≤4 there were significant differences between worsening renal function, increased left ventricle (LV) mass and LA volume index (LAV-I). However, in individuals with a score ≥4, the difference was only observed in relation to LAV-I.

Although natriuretic peptides are part of the diagnosis of HFpEF in the ESC guideline, their values did not contribute the score. NT-proBNP values were missed in 24% of the patients enrolled in the elaboration of the score because some cardiologists did not request the test during clinical evaluation³. Our data show that BNP was higher in patients with HFpEF compared to individuals without HFpEF, regardless of the H₂FPEF score.

The Meta‐Analysis Global Group in Chronic Heart Failure (MAGGIC)⁷, a risk score composed of 13 clinical variables, evaluated patients with HF across the spectrum of LVEF. Among the 13 variables used in the MAGGIC score, three were common to the H₂FPEF score (age, BMI and hypertension). The MAGGIC score did not use echocardiographic parameters and, like H₂FPEF, natriuretic peptides values were not considered. Of the patients defined with HFpEF (n = 407), followed during 3.6 ± 1.8 years, 28% died, 32% were hospitalized for HF and 55% had cardiovascular hospitalization and/or death. When compared to our assessment of the H₂FPEF score, we observed similar values in relation to the composite outcome observed in the MAGGIC score (55%) and in H₂FPEF, with a score ≥ 4 (53%). The H₂FPEF score, like the MAGGIC, is a simple score, but with a smaller number of variables, and shows to be useful for morbidity and mortality risk stratification in HFpEF.

The study has limitations related to a single center design, the relative small sample size, with female predominance, and the score was applied retrospectively. Multicenter studies with large populations are needed to confirm our data.

A H₂FPEF score ≥4 indicates a worse prognosis in patients with HFpEF assisted in primary care. Our data show that a low-cost, easy-to-apply score, such as the H₂FPEF, can help physicians in primary care in the risk stratification of HFpEF patients.