AB-HFPEF score: A new and improved HFpEF prediction tool for the Indian patient

Abstract Background/Introduction Heart failure with preserved ejection fraction (HFpEF) remains underdiagnosed in low-middle income countries including India. The simple and validated H2FPEF score has largely replaced the diagnostic need for invasive right heart catheterization. The score has therapeutic implications by stratifying patients into low, intermediate and high-risk groups. The relevance of this score is yet to be ascertained in the Indian population. Purpose We hypothesized that the H2FPEF score may fall short in accurately predicting HFpEF in our population, thus warranting a new score. Methods We conducted a prospective observational study over one year at the out-patient department of a tertiary-care hospital in India. Patients presenting with clinical features of heart failure were screened and enrolled in the study. Demographic, clinical, laboratory and echocardiographic details were recorded by the principal investigator using an online data collection tool. Patients were stratified into ‘low risk’, ‘intermediate risk’ and ‘high risk’ probabilities, with respective cut-off values of 0-3, 4-6, and 7-9 using the point-based score, and <30%, 30-59%, and >60% via the continuous model of H2FPEF score. Pearson’s chi-square test identified significant risk factors that were purposed into a novel AB-HFPEF score. Cohen’s kappa correlation determined the degree of agreement in the risk stratifications of the H2FPEF and the AB-HFPEF score, using the continuous scoring model as the reference. Results Among the 189 patients screened, 137 were enrolled in the study. The baseline characteristics are recorded in Table 1. Pedal edema and uncontrolled hypertension were noteworthy risk factors. A novel AB-HFPEF score was subsequently designed and scored as follows: Age (> 60 years) - 1, BMI (> 30 kg/m2) - 2, uncontrolled Hypertension (>140/90 mmHg) - 1, Filling pressure (E/e' > 9) - 1, Pulmonary Artery Systolic Pressure (> 35 mmHg) - 1, pedal Edema - 1, atrial Fibrillation - 3. Receiver operating characteristics (ROC) curve analysis demonstrated an area under the ROC curve (AUC) of 0.85 (95%CI, 0.78 to 0.91) for ‘low risk’ strata and 0.87 (95%CI, 0.81 to 0.93) for ‘high risk’ strata. The optimal stratification was 0-2, 3-4, and 5-10 points for the ‘low risk’, ‘intermediate risk’, and ‘high risk’ respectively. There was a moderate agreement of the AB-HFPEF score with the reference score (κ = 0.48 (95% CI, 0.36 to 0.60), p < 0.001), while the point-based H2FPEF score had only a slight agreement (κ = 0.15 (95% CI, 0.05 to 0.25), p < 0.001), as illustrated in Figure 1. Conclusion(s) The novel AB-HFPEF score performs better risk stratification in Indian patients with HFpEF as compared to the point-based H2FPEF score. We hence propose the AB-HFPEF score as an instrument for tailored cardiology care in the Indian demographic, laying the cornerstone for larger validation and prognostication studies.Table 1:Baseline characteristicsFigure 1:Heat Map Illustration