Role of a Prediction Score of Heart Failure with Left Ventricular Preserved Ejection Fraction in the Differential Diagnosis of Pulmonary Hypertension

Abstract

The distinction between pulmonary hypertension (PH) due to heart failure with left ventricular preserved ejection fraction (HFpEF) and idiopathic pulmonary arterial hypertension (IPAH) has important clinical implications. These distinction between pre and post-capillary PH is based on a cutoff value of pulmonary arterial wedge pressure value (PAPW) >15 mmHg in the latter. However, a value between 12 and 15 mmHg is associated with a higher probability of post-capillary pulmonary hypertension. In addition, the probability of HFpEF may be assessed by the non invasive H2FPEF score. We sought to evaluate the performance of the latter in the differential diagnosis of pulmonary hypertension and its discriminating power when the PAPW is between 12 and 15 mmHg. In this single center retrospective study, we included patients with left ventricular ejection fraction >45% and PH confirmed by right cardiac catheterization between 01/01/2010 and 31/12/2018. The H2FPEF score was calculated for the entire population and then as a function of the PAPW value (<12 mmHg, between 12 and 15 mmHg and >15 mmHg). Each component of the score was analyzed to determine if there is a dominant factor. In 303 patients, an H2FPEF score = 4.5 predicts the presence of PAPW >15 mmHg with a sensitivity of 65% and a specificity of 74%. To predict a PAPW between 12 and 15 mmHg the ROC curve of the H2FPEF score has an area under the curve of 0.52 (AUC = 0.52 [95% CI 0.45-0.59]). Variables that are independently associated with a PAPW > 15mmHg are: treatment with 2 or more antihypertensive drugs (OR = 2.9, IC [95%: 1.5-5.8], p = 0.002), and the presence of atrial fibrillation (OR = 4.8, IC [95%: 1.7 -13.8], p = 0.003). The H2FPEF score may be used to guide the diagnosis of post-capillary PH, mainly in the presence of atrial fibrillation and prescription of two antihypertensive drugs. The score is not efficient when the PAPW is measured between 12 and 15 mmHg.