H₂FPEF score
Likelihood of heart failure with preserved ejection fraction in unexplained dyspnoea
- Mayo Clinic (derivation)
Sources last checked: 2026-10-13
H₂FPEF score
Likelihood of heart failure with preserved ejection fraction in unexplained dyspnoea
HFpEF unlikely; the derivation authors propose this range for ruling out HFpEF, with other causes of dyspnoea then more likely.
Derived in patients with unexplained exertional dyspnoea and LVEF ≥ 50 % referred for invasive exercise testing at a single US centre. The bands are the authors' suggested use, not formal guideline cut-offs; the ESC 2021 HF guideline uses its own simplified diagnostic approach.
Interpretation
| 0–1 — low | HFpEF unlikely; the derivation authors propose this range for ruling out HFpEF, with other causes of dyspnoea then more likely. |
|---|---|
| 2–5 — intermediate | Indeterminate: for this range the derivation authors suggest further testing (e.g. natriuretic peptides, exercise echocardiography or invasive haemodynamic exercise testing). |
| 6–9 — high | HFpEF likely; the authors suggest this range is sufficient to make the diagnosis without further testing in most patients. |
What is the H₂FPEF score?
The H₂FPEF score estimates how likely it is that unexplained exertional dyspnoea with a preserved ejection fraction is caused by heart failure (HFpEF). Reddy and colleagues at the Mayo Clinic derived it in 2018 from 414 patients who underwent invasive haemodynamic exercise testing, the diagnostic reference standard, and tested it in a separate cohort. It combines four clinical and two echocardiographic variables into a 0–9 point score.
When to use it
- Unexplained exertional dyspnoea with LVEF ≥ 50 % where HFpEF is a possible cause.
- Gauging how much further testing (stress echo, invasive exercise haemodynamics) could add.
- Structuring the work-up alongside natriuretic peptides and echocardiography.
When not to use it
- Reduced or mildly reduced ejection fraction (LVEF < 50 %).
- Dyspnoea with an obvious alternative explanation such as significant valve disease, pericardial disease, infiltrative cardiomyopathy or primary lung disease.
- Acute decompensated heart failure, where the diagnosis is usually clinical.
How it is calculated
| Criterion | Points |
|---|---|
| Heavy: BMI > 30 kg/m² | +2 |
| Hypertensive: ≥ 2 antihypertensive drugs | +1 |
| Atrial fibrillation (paroxysmal or persistent) | +3 |
| Pulmonary hypertension: echo PASP > 35 mmHg | +1 |
| Elder: age > 60 years | +1 |
| Filling pressure: echo E/e′ > 9 | +1 |
Clinical pearls and limitations
- Derived in patients with unexplained exertional dyspnoea and LVEF ≥ 50 % referred for invasive exercise testing at a single US centre. The bands are the authors' suggested use, not formal guideline cut-offs; the ESC 2021 HF guideline uses its own simplified diagnostic approach.
- Atrial fibrillation carries 3 points — almost half the way to the high range on its own.
- Each point roughly doubled the odds of HFpEF in the derivation cohort.
- Obesity and age make the score climb in many dyspnoeic patients; an intermediate result is common; the authors frame it as a reason for further testing, not a diagnosis.
- The ESC 2021 HF guideline mentions H₂FPEF and HFA-PEFF but diagnoses HFpEF with a simplified approach: symptoms/signs, LVEF ≥ 50 % and objective evidence of structural or functional abnormality or raised natriuretic peptides.
Frequently asked questions
What does H₂FPEF stand for?
Heavy (BMI > 30), Hypertensive (≥ 2 drugs), atrial Fibrillation, Pulmonary hypertension (PASP > 35 mmHg), Elder (> 60 years) and Filling pressure (E/e′ > 9).
What H₂FPEF score is high?
6–9 points: HFpEF is likely. 0–1 makes it unlikely; 2–5 is intermediate, a range for which the authors suggest further testing.
What is the difference between H₂FPEF and HFA-PEFF?
H₂FPEF is a short clinical-echo score from a single US centre; HFA-PEFF is the Heart Failure Association (ESC) stepwise algorithm that also uses natriuretic peptides and more echo criteria.
Evidence and guidelines
- Primary source: 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.
- McDonagh TA et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J 2021;42:3599-3726.
- Reddy YNV et al. 2018 — full text (PMC).
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