Disagreement of ESC guidelines from 2016 and 2021 and HFA-PEFF and H2 FPEF scores in diagnosis of heart failure with preserved ejection fraction in atrial fibrillation patients
Authors: Gawalko M , Adriaans B , Habibi Z , Weerts J , Posea P , Hubers S , Verhaert D , Chaldoupi S M , Ter Bekke R , Den Uijl D , Luermans J , Van Empel V , Schotten U , Vernooy K , Linz D 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The gold-standard test for HFpEF diagnosis remains invasive assessment of left ventricular end-diastolic pressures but noninvasive diagnostic scoring systems have been developed to aid accurate diagnosis. However, the diagnosis of HFpEF in patients with AF is more difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se.

Purpose
To compare the guidelines and scoring systems for HFpEF diagnosis in patients with AF, and to indicate the most relevant clinical and echocardiographic parameters supporting the diagnosis of HFpEF in an AF cohort.

Methods
Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Clinical characteristics and transthoracic echocardiography examination was collected at baseline visit. The European Society of Cardiology (ESC) guidelines from 2016 and 2021 as well as scoring systems (HFA-PEFF and H2FPEF scores) were used to diagnose HFpEF. In the H2FPEF score, patients with AF alone, score of 3, were assessed as group with the low risk for HFpEF (instead of intermediate risk according to the H2FPEF score), as all enrolled patients had AF. Multiple logistic regression was performed to find optimal parameters predicting HFpEF, that was defined as diagnosis of HFpEF according to all following scores: ESC guidelines from 2016 and 2021 and high risk in HF2FPEF and HF-PEFF scores.

Results
We analysed 325 patients (median age 65 [59-72], 36% women). Considerable differences were observed in HFpEF diagnoses when stratifying patients according to ESC 2016 and ESC 2021 guideline definitions; the percentage of HFpEF patients reduced from 55% (n=180) to 28% (n=90). The agreement of HF2PEF score relative to HFA-PEFF score was 46% (n=25/55), 54% (n=115/213) and 35% (n=20/57) of patients regarding low, intermediate and high risk for HFpEF, respectively. Overall, 5.8% of patients (n=19) had HFpEF (Figure 1). These 19 patients were older (median age 70 vs 65, p&lt;0.001), had more often persistent AF (63% vs 30%; p&lt;0.001) and vascular disease (37% vs 14%, p=0.017) as compared to those without HFpEF. Based on multiple logistic regression, higher values of N-terminal-pro hormone BNP (NT-proBNP; OR 1.02, 95CI 1.01-1.03) and LA volume index (LAVI; OR 1.13, 95%CI 1.04-1.23) were independent predictors of having HFpEF in AF population. The NT-proBNP of 45 pmol/L and LAVI of 45ml/kg2 were ideal cutoffs and constructed a model to predict HFpEF which fitted with a concordance index of 0.91 (95% CI 0.87–0.94) (Figure 2).

Conclusions
The differences in HFpEF definition in the guidelines and various scoring systems lead to considerable difference in stratification of HFpEF in AF patients. In our population, just 5.8% of AF patients were diagnosed with HFpEF regarding ESC guidelines and high risk for HFpEF in scoring systems.