Disclosures: No conflict to disclose.
Key words: HFpEF, atrial fibrillation, cardioversion, scores
Background: Previous studies suggest that risk stratification in HFpEF patients is challenging due to the heterogeneity of the syndrome and its comorbidities. In this study, we investigated the prognostic performance of the H2FPEF and HFA-PEFF scores for predicting procedural and long-term outcomes in HFpEF patients undergoing electrical cardioversion for atrial fibrillation.
Methods: HFpEF probability was assessed using the H2FPEF and HFA-PEFF scores. For the H2FPEF score, 0–1 points indicated low probability, 2–5 points intermediate probability, and ≥6 points high probability of HFpEF. For the HFA-PEFF score, 0–1 points indicated HFpEF was very unlikely, 2–4 points required further evaluation, and ≥5 points supported the diagnosis of HFpEF. Only patients with left ventricular ejection fraction (LVEF) >40% were included. All-cause mortality, hospitalization for heart failure, and atrial arrhythmia recurrence were analyzed at 1-year follow-up.
Results: A total of 274 patients with complete H2FPEF data (mean age 74.1 ± 7.5 years; 62.8% male; mean LVEF 55.8 ± 7.1%) and 196 patients with complete HFA-PEFF data (mean age 76.0 ± 7.5 years; 58.7% male) were included. Our analysis shows that the H2FPEF score is associated with reduced initial cardioversion success and increased long-term arrhythmia recurrence. Patients with low H2FPEF scores achieved a success rate of 93% compared to 84.8% in those with high scores (p = 0.039), while arrhythmia recurrence increased from 15.9% to 50.9% (p < 0.001). In contrast, the HFA-PEFF score showed no association with initial success (89.8% vs. 86.6%, p = 0.518) or long-term recurrence (40.3% vs. 41.6%, p = 0.982). Additionally, a higher H2FPEF score correlated with increased risk of mortality and heart failure hospitalization at 1-year (high vs. low score: p = 0.0485), whereas the HFA-PEFF score showed no difference (p = 0.122). These findings suggest that the H2FPEF score, which incorporates factors such as left atrial size, BMI, hypertension, and age, may provide greater prognostic value for predicting both procedural and long-term outcomes in HFpEF patients compared to the HFA-PEFF score.
Conclusion: In HFpEF patients undergoing electrical cardioversion for atrial fibrillation, higher H2FPEF scores were associated with lower acute cardioversion success, a markedly increased risk of recurrent atrial arrhythmias, and higher rates of mortality and heart failure hospitalization during follow-up. These results suggest that the H2FPEF score is a valuable tool for identifying high-risk HFpEF patients in the rhythm-control setting and may support more individualized decision-making and follow-up strategies in this challenging population.
