Clinical Investigations
Value of Stress Echocardiography in Evaluation of Dyspnea
Prognostic Value of the MAGGIC Score, H2FPEF Score, and HFA-PEFF Algorithm in Patients with Exertional Dyspnea and the Incremental Value of Exercise Echocardiography

https://doi.org/10.1016/j.echo.2022.05.006Get rights and content

Highlights

  • Prognostic strategies in HFpEF are insufficiently defined.

  • Diagnostic scores H2FPEF and HFA-PEFF may facilitate risk stratification.

  • When limited to resting data, both scores are prognostically comparable to MAGGIC score.

  • Extending HFA-PEFF score with exercise diastolic data improves outcome prediction.

Background

The strategies for improving outcomes in heart failure with preserved ejection fraction (HFpEF) are insufficiently defined, which affects optimal patient management. The aim of the study was to compare the prognostic value of the previously validated Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score with 2 approaches primarily dedicated to diagnosing HFpEF: the H2FPEF score (heavy, 2 or more hypertensive drugs, atrial fibrillation, pulmonary hypertension [pulmonary artery systolic pressure >35 mm Hg], elder age >60, elevated filling pressures [E/e' > 9]) and the HFA-PEFF algorithm (Heart Failure Association diagnostic algorithm—pretest assessment; echocardiography and natriuretic peptide score; functional testing; final etiology) in patients with exertional dyspnea categorized as HFpEF.

Methods

Clinical and biochemical variables and echocardiographic resting and exercise data from 201 enrollees were retrospectively analyzed. Participants were followed for 48 (24-60) months for HF hospitalization and cardiovascular death.

Results

Seventy-four patients (36.8%) met the study outcome. In sequential Cox analysis, the addition of MAGGIC risk score, H2FPEF score, and HFA-PEFF step 2 (including only resting echocardiographic evaluation) and step 3 (including also exercise diastolic data) algorithms to the base model comprising brain natriuretic peptide and peak oxygen uptake improved the predictive power for the study endpoint. Harrell's c statistic showed a greater predictive ability for the HFA-PEFF step 3 algorithm than for each of the other scores (c index 0.715 vs 0.637, 0.644, and 0.638 for MAGGIC, H2FPEF, and HFA-PEFF step 2, respectively; all P < .05). No significant differences were found for other between-score comparisons.

Conclusion

In patients with exertional dyspnea and a possible HFpEF, the H2FPEF score and HFA-PEFF algorithm limited to resting echocardiography provide prognostic value comparable to the MAGGIC risk score. Extending the HFA-PEFF algorithm with exercise diastolic data is associated with a significant improvement in risk stratification.

Section snippets

Patient Selection

In this retrospective analysis, we included data prospectively collected from 201 patients with exertional dyspnea who were recruited from hospital clinics at a tertiary care cardiology center (University Hospital) and who met the HFpEF criteria in place at the time of recruitment (i.e., between 2012 and 2015): (1) signs and symptoms of HF (dyspnea, fatigue, and exercise intolerance) consistent with New York Heart Association (NYHA) functional class II or III with reduced exercise capacity

Patient Characteristics and Events

The studied population was characterized by a predominance of female sex and high frequency of hypertension, diabetes, and obesity or overweight. These characteristics as well as echocardiographic data are presented in Table 2. The average score was 14.8 for MAGGIC, 4.5 for H2FPEF, 4.2 for the HFA-PEFF step 2 algorithm, and 4.6 for the HFA-PEFF step 3 algorithm. Using the predefined diagnostic cutoffs recommended for the identification of HFpEF, 60 (30%) enrollees had H2FPEF score ≥6, while 83

Discussion

This study demonstrates that in patients with exertional dyspnea meeting the 2007 European Society of Cardiology criteria of HFpEF, the MAGGIC risk score, H2FPEF score, and HFA-PEFF algorithm including only resting echocardiographic evaluation (i.e., limited to the diagnostic workup step 2) show similar abilities to predict the risk of HF hospitalization or death. The addition of information from diastolic exercise echocardiography (advanced workup step 3) provides a significant improvement in

Conclusion

In patients with exertional dyspnea and a possible diagnosis of HFpEF according to the 2007 European Society of Cardiology criteria, the H2FPEF score and HFA-PEFF algorithm limited to step 2 provide prognostic value comparable to the MAGGIC risk score. The inclusion of exercise diastolic data is associated with a significant improvement in risk stratification by the HFA-PEFF algorithm. Accordingly, the HFpEF diagnostic scores, especially the HFA-PEFF algorithm with step 3, where appropriate,

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    Conflicts of Interest: None.

    This study was funded by grant ST-678 from the Wroclaw Medical University, Wroclaw, Poland.

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