Improving the Diagnosis of HFpEF: A Comparison of the H₂FPEF Score and the 2025 ASE Diastolic Function Guideline Recommendations Using Invasive Hemodynamics as the Gold Standard

Background: The H₂FPEF score was developed for heart failure with preserved ejection fraction (HFpEF) diagnosis based on clinical parameters, septal E/e′ ratio and pulmonary artery systolic pressure. Diagnostic accuracy can be improved by additional echocardiographic parameters. Objectives: This report aims to study the impact of echocardiography in improving the accuracy of The H₂FPEF score, using the score as the initial step for HFpEF diagnosis. Methods: Stable patients with ejection fraction ≥50% who underwent right heart catheterization and echocardiographic imaging within 30 days were included. H₂FPEF score was computed. Echocardiographic measurements recommended in ASE (American Society of Echocardiography) 2025 diastolic function guidelines update were included. Results: There were 511 patients with 237 having pulmonary capillary wedge pressure >15 mm Hg at rest or >25 mm Hg with exercise. Heart failure probability of <30% was present in 60 patients, whereas 58 had a probability of 30%-49%, 113 had a probability of 50%-80%, and 280 had a probability of >80%. Accuracy of The H₂FPEF score was not improved with the addition of echocardiographic assessment when HF probability was <30% (P = 0.083). For all other probabilities, echocardiographic assessment significantly added to H₂FPEF score accuracy. Net reclassification improvement was 1.38 (P < 0.001), and integrated discrimination improvement was 0.38 (P < 0.001). Conclusions: The H₂FPEF score has good accuracy in excluding HF diagnosis when HF probability based on the score is <30%. When probability is >30%, 2025 ASE diastolic function guidelines approach to the estimation of mean left atrial pressure adds to accuracy.