Why use it

HFpEF is the most common form of heart failure and is frequently underdiagnosed due to its nonspecific presentation and the historical requirement for invasive hemodynamic confirmation. The H2FPEF score provides a validated, non-invasive clinical prediction tool calculated from readily available clinical and echocardiographic data, facilitating earlier and more accurate diagnosis, appropriate treatment initiation, and informed decision-making about the need for more invasive testing. It is endorsed in the 2022 AHA/ACC/HFSA Heart Failure Guidelines.

About

The H2FPEF score was developed by Reddy and colleagues at the Mayo Clinic and published in Circulation in 2018. It estimates the probability of heart failure with preserved ejection fraction (HFpEF) in patients with unexplained exertional dyspnea and preserved left ventricular ejection fraction (≥50%), without the need for invasive hemodynamic testing. The score uses six clinical and echocardiographic variables, each assigned weighted points based on their independent association with a hemodynamic diagnosis of HFpEF (defined as pulmonary capillary wedge pressure ≥15 mmHg at rest or ≥25 mmHg during exercise on right heart catheterization). The acronym H2FPEF encodes: Heavy (obesity, BMI >30), Hypertensive (on ≥2 antihypertensive agents), atrial Fibrillation (paroxysmal or persistent), Pulmonary hypertension (PASP >35 mmHg), Elder (age >60), and elevated Filling pressures (E/e' >9). Scores range from 0 to 9; very low scores (0–1) effectively exclude HFpEF with >95% NPV, while high scores (≥6) confirm it with >90% probability. Intermediate scores (2–5) require additional evaluation with exercise echocardiography or invasive hemodynamic testing.

When to use

Patients with unexplained exertional dyspnea and preserved LVEF (≥50%) in whom HFpEF is suspected
Differentiating HFpEF from non-cardiac causes of dyspnea (obesity, deconditioning, pulmonary disease)
Determining the need for exercise echocardiography or right heart catheterization in ambiguous cases (score 2–5)
Avoiding unnecessary invasive testing in patients with very high (≥6) or very low (0–1) probability of HFpEF
Identifying candidates for HFpEF-specific clinical trials or treatment pathways

Formula

H2FPEF Score = Sum of the following: H — Heavy (BMI > 30 kg/m²): +2 points H — Hypertensive (on ≥2 antihypertensive agents): +1 point A — Atrial Fibrillation (paroxysmal or persistent): +3 points P — Pulmonary Hypertension (PASP > 35 mmHg): +1 point E — Elder (age > 60 years): +1 point F — Filling Pressure (E/e' ratio > 9): +1 point Range: 0–9 Interpretation: 0–1: Low probability of HFpEF (<10%) 2–5: Intermediate — exercise echo or RHC recommended 6–9: High probability of HFpEF (>90%)

Pearls & pitfalls

The H2FPEF score was validated in 267 patients with preserved LVEF who underwent rest and exercise right heart catheterization — the gold standard for HFpEF diagnosis.
Atrial fibrillation contributes the most points (3) in the score, reflecting its very strong association with elevated left atrial pressures in HFpEF.
Obesity (BMI >30) contributes 2 points — it is both a cause and comorbidity of HFpEF and is associated with a specific obese HFpEF phenotype.
E/e' ratio >9 by Doppler echocardiography is a surrogate for elevated left ventricular filling pressures and a key diagnostic criterion for HFpEF per ASE/EACVI guidelines.
A score of 0 or 1 has a very high negative predictive value (NPV >95%) for ruling out HFpEF — avoid unnecessary further workup in these patients.
Exercise echocardiography (diastolic stress test) is the preferred next step for intermediate scores (2–5), as latent hemodynamic abnormalities are unmasked only with exercise in many HFpEF patients.
The H2FPEF score complements but does not replace the ASE/EACVI 2016 echocardiographic diastolic function grading algorithm.
An H2FPEF score ≥6 has a PPV >90% for hemodynamically confirmed HFpEF, potentially avoiding the need for invasive catheterization in many patients.
SGLT2 inhibitors (dapagliflozin, empagliflozin) now have a class IIa recommendation for HFpEF per the 2022 AHA/ACC/HFSA guidelines.

Next steps

Score 0–1 (Low probability, <10%): HFpEF unlikely. Investigate alternative causes of dyspnea — obstructive or restrictive pulmonary disease, obesity hypoventilation syndrome, pulmonary arterial hypertension, anemia, deconditioning. No further HFpEF-specific testing required. Score 2–5 (Intermediate probability): Further evaluation required — exercise echocardiography (preferred non-invasive approach) or invasive right heart catheterization at rest and exercise. Score 6–9 (High probability, >90%): HFpEF highly confirmed. Initiate HFpEF-targeted therapy: diuretics for volume overload; treat underlying comorbidities (HTN target <130/80, AF rate/rhythm control, obesity, DM with SGLT2 inhibitor). Refer to heart failure specialist.

Evidence

Reddy YNV et al. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Circulation. 2018;138(9):861-870. PMID:29792299. Derivation cohort: 267 patients (Mayo Clinic). AUC 0.841. Validated prospectively in: Andersen OS et al. Eur Heart J. 2020 (AUROC 0.80). The H2FPEF score is endorsed in the 2022 AHA/ACC/HFSA Heart Failure Guidelines as a reasonable tool for HFpEF diagnosis (Class IIa).

References

Reddy YNV et al. A Simple, Evidence-Based Approach to Help Guide Diagnosis of Heart Failure With Preserved Ejection Fraction. Circulation. 2018;138(9):861-870. — link
Pieske B et al. How to diagnose heart failure with preserved ejection fraction: the HFA-PEFF diagnostic algorithm. Eur Heart J. 2019;40(40):3297-3317. — link
Heidenreich PA et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol. 2022;79(17):e263-e421. — link

H2FPEF Score for Heart Failure with Preserved EF

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