Simple clinical prediction rule determines risk of heart failure with preserved ejection fraction

Reference

Reddy YNV, Carter RE, Obokata M, Redfield MM, Borlaug BA. A simple, evidence-based approach to help guide diagnosis of heart failure with preserved ejection fraction. Circulation 2018;138(9):861-870.

Synopsis

These authors identified patients who had been referred to the Mayo Clinic for unexplained dyspnea and underwent invasive testing. The reference standard was right-sided coronary catheterization, with measurement of pressures at rest and, if necessary, during exercise. Predictors were ascertained by chart review. This is ordinarily a red flag, but in this case the predictors were relatively unambiguous (eg, body mass index and number of medications for hypertension) and the chart review was done in parallel by 2 investigators using clear prespecified definitions for each variable. The derivation population consisted of 414 consecutive patients, 64% of whom had HFpEF. The validation population was 100 consecutive patients at the same center, with a prevalence of HFpEF of 61%. The mean age of participants was 56 years for those with noncardiac dyspnea and 68 years for those with HFpEF; 60% were women. Logistic regression was used to identify independent predictors, and points were assigned to each predictor based on the beta-coefficient. The independent predictors were body mass index greater than 30 kg/m2 (2 points), taking 2 or more antihypertensive drugs (1 point), paroxysmal or persistent atrial fibrillation (3 points), Doppler echocardiogram with pulmonary artery systolic pressure greater than 35 mm Hg, age 60 years or older, and Doppler echocardiogram showing an E/e ratio of more than 9. In the validation group, the observed proportion with HFpEF ranged from 0% with 0 points to more than 90% with at least 6 points. The authors suggest that the diagnosis can be provisionally ruled out for patients with 0 or 1 points, ruled in for patients with more than 5 points, and that further testing is needed for those with 2 to 5 points.