Diagnostic Accuracy of the H2FPEF Score for Identifying Heart Failure with Preserved Ejection Fraction in Adults with Suspected HFpEF at a Tertiary Care Hospital in Pakistan

Abstract

Objective: To evaluate the diagnostic accuracy of the heart failure with preserved ejection fraction (HFpEF) score for identifying HFpEF in adults presenting with suspected HFpEF and to explore its association with selected in-hospital clinical outcomes. Methodology: This prospective observational diagnostic-accuracy study was conducted at Lady Reading Hospital, Peshawar, Pakistan, between January and December 2025. A total of 300 consecutive adults with symptoms suggestive of heart failure, preserved left ventricular ejection fraction (≥50%), and at least one structural or functional echocardiographic abnormality were enrolled. The H2FPEF score was calculated prospectively using predefined criteria. The reference standard diagnosis of HFpEF was established independently by a panel of three consultant cardiologists using clinical findings and echocardiographic evidence in accordance with contemporary European Society of Cardiology and HFA-PEFF recommendations. Diagnostic accuracy was evaluated using receiver operating characteristic (ROC) curve analysis, and sensitivity, specificity, predictive values, likelihood ratios, and overall accuracy were calculated at the exploratory cut-off value of ≥5. Results: Among the 300 enrolled participants, the expert panel classified 240 (80.0%) as having HFpEF and 60 (20.0%) as non-HFpEF. The H2FPEF score demonstrated good diagnostic discrimination with an area under the ROC curve (AUC) of 0.86 (95% CI: 0.82–0.90). At the exploratory cut-off value of ≥5, sensitivity was 84.2% (95% CI: 79.0–88.2), specificity 76.7% (95% CI: 64.6–85.6), positive predictive value 93.5% (95% CI: 89.4–96.1), negative predictive value 54.8% (95% CI: 44.2–65.0), and overall diagnostic accuracy 82.7% (95% CI: 78.0–86.5). Higher H2FPEF score categories were significantly associated with longer hospital stay and increased ICU admission (both p<0.001), whereas the observed increase in in-hospital mortality was not statistically significant (p=0.17). Conclusion: The H2FPEF score demonstrated good diagnostic accuracy for identifying HFpEF among adults with suspected disease in this tertiary-care cohort. The exploratory threshold of ≥5 provided a favorable balance between sensitivity and specificity; however, because the study population represented a selected high-prevalence referral cohort, external validation in broader clinical settings is warranted before routine implementation.