Comparing diagnostic accuracy of HFA-PEFF score vs. ESC guidelines definition of heart failure with preserved ejection fraction: findings from a pacemaker systematic screening program

The diagnosis of heart failure with preserved ejection fraction (HFpEF) in pacemaker patients is challenging, as standard assessment criteria can be affected by artificial pacing. Although the European Society of Cardiology (ESC) guidelines and the Heart Failure Association Pre-test Assessment, Echocardiography & Functional Testing, and Final Etiology (HFA-PEFF) score provide recommendations for HFpEF diagnosis, the comparative performance of these methods in a pacemaker population has never been established.

Evaluate the concordance between the European Society of Cardiology (ESC) guidelines for HF and the HFA-PEFF score for diagnosing HFpEF in pacemaker patients.

Cross-sectional, single-center screening study for HF in all patients submitted to a pacemaker implant with right ventricular apical pacing between January 2008 and December 2022. Patients underwent complete echocardiographic assessment, exercise echocardiography, NT-proBNP measurement, clinical examination, and pacemaker interrogation. We used the 2023 ESC guidelines to diagnose HF and evaluated concordance with the HFA-PEFF score using Cohen’s kappa and overall agreement. Concordance was categorized as poor (0–0.20), fair (0.21–0.40), moderate (0.41–0.60), good (0.61–0.80), and optimal (0.81–1). Diagnostic accuracy was evaluated by sensitivity, specificity, PPV, and NPV, with ESC criteria as the reference. ROC analysis was conducted to assess the discriminative ability of an HFA-PEFF score ≥5 for HFpEF diagnosis.

A total of 342 patients (median age 78 ± 9 years, 60.1% male) were screened. 35.7% (n=122) had HFpEF, 6.1% (n=21) had HFmrEF, 3.8% (n=13) had HFrEF, and the remaining 54.4% (n=186) had no HF, according to ESC Guidelines. Using the HFA-PEFF score the prevalence of HFpEF was 32,9% (n=109). Concordance between the ESC Guidelines and HFA-PEFF score criteria was high, with a Cohen’s kappa value of 0.88 (95% CI: 0.83–0.94, P < 0.001), reflecting optimal agreement. The overall agreement rate was 94.4%, with the HFA-PEFF score showing a PPV of 87,7% and a NPV of 98,9%. Both criteria classified 107 patients as HFpEF and 183 patients as non-HF. Discrepancies were minimal, with only 2 cases classified as HFpEF by HFA-PEFF score but not by the ESC criteria and 15 cases classified as HFpEF by ESC guidelines but not by HFA-PEFF score. ROC analysis of the HFA-PEFF score revealed moderate discriminative ability for diagnosing HFpEF in our cohort, with a conventional and optimal cut-off of 5. At this threshold, the score achieved an AUC of 0.76 (95% CI: 0.71–0.80), with a sensitivity of 87.7% and specificity of 63.8%.

This study found a high prevalence of HFpEF in pacemaker patients and strong concordance between the HFA-PEFF score and ESC guidelines, a previously unreported finding. The HFA-PEFF score appears to be a reliable tool for HFpEF screening, enhancing diagnostic accuracy and clinical decisions in this population.