Objective: Heart failure with preserved ejection fraction (HFpEF) now accounts for the majority of heart failure cases worldwide, and its prevalence continues to rise. Despite this, diagnosis remains challenging because of substantial patient heterogeneity and the absence of universally accepted diagnostic standards. To address these challenges, the H2FPEF (Heavy, Hypertensive, Atrial Fibrillation, Pulmonary Hypertension, Elderly, and Filling Pressure) and HFA-PEFF (Heart Failure Association–Pre-test Assessment, Echocardiography, and Functional Testing) scoring systems were developed. In this systematic review and meta-analysis, we evaluated the accuracy of these algorithms for identifying HFpEF and their utility in clinical practice.
Materials and Methods: A comprehensive literature search was conducted using PubMed, Embase, the Cochrane Library, and Web of Science to identify studies assessing the diagnostic accuracy of H2FPEF and/or HFA-PEFF in adults with suspected HFpEF. Study quality was appraised using the QUADAS-2 (Quality Assessment of Diagnostic Accuracy Studies–2) tool. Diagnostic metrics were synthesized using bivariate random-effects models. The review adhered to PRISMA (the Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, and the certainty of evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.
Results: Ten studies met the inclusion criteria, representing diverse patient populations and clinical settings. The H2FPEF algorithm demonstrated a pooled sensitivity of 0.76 (95% confidence interval [CI]: 0.56-0.87) and a specificity of 0.72 (95% CI: 0.59-0.82), with area under the curve (AUC) values ranging from 0.74 to 0.886. For the HFA-PEFF algorithm, pooled sensitivity was 0.70 (95% CI: 0.61-0.78), while specificity was substantially higher at 0.90 (95% CI: 0.85-0.94), with an AUC of 0.90. When both algorithms were applied to the same patient cohorts, 41% of cases yielded discordant diagnostic classifications.
Conclusion: Both scoring systems provide valuable diagnostic insights but exhibit unique strengths and limitations depending on the patient population and clinical context. These tools should be used to complement, rather than replace, comprehensive clinical evaluation. An effective strategy is to use the H2FPEF score as an initial screening tool, followed by the HFA-PEFF algorithm for confirmation; in cases of discordance, further advanced diagnostic testing is recommended.