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Is it HFpEF?

The H2FPEF, HFA-PEFF and HFpEF-ABA scores from the 2026 ACC HFpEF pathway. They support a diagnosis; they do not make one. For HFpEF only (LVEF 50% or more).

The same values as in the patient editor in the header and on the other pages: change one here and it changes there.

Sex

Same as the rhythm in the patient editor.

H2FPEF score

1 / 9

Screening score; more sensitive than specific. Echo values are needed for two of the six items.

  • Heavy: BMI >30 kg/m²not entered0/2
  • On ≥2 antihypertensivesnot entered0/1
  • Atrial fibrillation0/3
  • Pulmonary hypertension: PASP >35 mmHg on Doppler echocardiographynot entered0/1
  • Elder: age >60 years1/1
  • Filling pressure: E/e′ >9 on Doppler echocardiographynot entered0/1
1 of 9 points with 4 items not entered (a lower bound): below the ≥6 threshold the pathway calls highly suggestive; in the derivation cohort the odds of HFpEF doubled with each point.

HFpEF-ABA score

–

Three clinical variables (age, BMI, AF); designed for primary care. Printed alongside the other two scores in the pathway.

Enter the BMI above.

Three clinical variables (age, BMI, atrial fibrillation) give a probability of HFpEF through a logistic equation; the pathway notes that probability thresholds are not established, with low probability definable as <25%. Shown here because it is printed alongside the two main scores.

HFA-PEFF score (step E)

0 / 6

Confirmatory score. Each domain scores 2 for a major and 1 for a minor criterion, at most 2 per domain. Needs comprehensive echocardiography and a natriuretic peptide.

Functional 0

Major: Septal e′ <7 cm/s, or lateral e′ <10 cm/s, or average E/e′ ≥15, or TR velocity >2.8 m/s. Minor: Average E/e′ 9–14, or GLS <16%.

Morphological 0

Major: LAVI >34 mL/m², or LVMI ≥149 (men) / ≥122 (women) g/m² with RWT >0.42. Minor: LAVI 29–34 mL/m², or LVMI >115 (men) / >95 (women) g/m², or RWT >0.42, or LV wall thickness ≥12 mm.

Biomarker 0

Thresholds used: sinus rhythm. Major: Sinus rhythm: NT-proBNP >220 or BNP >80 pg/mL. Atrial fibrillation: NT-proBNP >660 or BNP >240 pg/mL. Minor: Sinus rhythm: NT-proBNP 125–220 or BNP 35–80 pg/mL. Atrial fibrillation: NT-proBNP 365–660 or BNP 105–240 pg/mL.

0 of 6 points (functional 0, morphological 0, biomarker 0, sinus-rhythm thresholds): HFpEF unlikely. No values entered for the functional and morphological and biomarker domains, so the score is a lower bound.

Each domain scores 2 (major) or 1 (minor) points, at most 2 per domain; ≥5 points means HFpEF, ≤1 point makes it unlikely, 2–4 calls for functional testing (F1) and then a search for a specific aetiology (F2).

The pathway suggests H2FPEF as the screening score (more sensitive) and HFA-PEFF for confirmation (more specific); with discordance, further testing. A therapeutic trial of HFpEF therapy is a reasonable first step when advanced testing is not available. Normal natriuretic peptides alone do not exclude HFpEF.

Natriuretic peptides run higher with reduced kidney function and lower with obesity; in advanced CKD, other objective evidence of raised filling pressures helps, and normal levels can help exclude HF.