J Card Fail 2026 Apr 06; doi: 10.1016/j.cardfail.2026.03.022.

Performance of the HFpEF-ABA, H2FPEF, and HFA-PEFF Algorithms in Heart Failure With Preserved Ejection Fraction: A Participant-Level Pooled Analysis of Randomized Clinical Trials.

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BACKGROUND: Several scores have been introduced to improve the diagnosis of heart failure with preserved ejection fraction (HFpEF). Whether these scores enhance risk stratification in established HFpEF remains uncertain. OBJECTIVES: In this analysis including persons with HFpEF, clinical outcomes according to different HFpEF diagnosis models were explored. METHODS: First, clinical outcomes and trial-specific treatment effects were evaluated according to HFpEF-ABA score in a participant-level pooled analysis of 5 clinical trials (CHARM-Preserved, I-PRESERVE, TOPCAT-Americas, PARAGON-HF, and DELIVER). Second, using echocardiography data (TOPCAT-Americas and PARAGON-HF), associations between the HFpEF-ABA, H2FPEF, and HFA-PEFF models and clinical outcomes were assessed. RESULTS: Among 15,318 participants, 38% and 62% had a low/intermediate and high HFpEF-ABA score, respectively. Higher HFpEF-ABA scores were incrementally associated with a higher rate of cardiovascular and mortality outcomes. Participants with a high vs low/intermediate HFpEF-ABA score experienced a 75% higher rate of cardiovascular death or HF hospitalization (hazard ratio [HR], 1.75; 95% CI, 1.62-1.89; P < .001). However, risk discrimination was limited (C statistic, 0.559; 95% CI, 0.550-0.567). Trial-specific treatment effects appeared consistent irrespective of HFpEF-ABA score. Among echocardiography substudy participants (n = 1300), only the H2FPEF (HR per unit increase, 1.06; 95% CI, 1.00-1.11) and HFA-PEFF (HR per unit increase, 1.10; 95% CI, 1.03-1.19) models were statistically significantly associated with cardiovascular death or HF hospitalization; risk discrimination was modest for all models (C statistic range, 0.524-0.529). CONCLUSIONS: While risk scores developed to improve HFpEF diagnosis were associated with adverse outcomes in this pooled trial analysis, their utility for risk stratification once HFpEF is established appears modest.

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