{
  "abstract": "Background and aims The Heavy, Hypertensive, Atrial fibrillation, Pulmonary hypertension, Elder, Filling pressure (H 2FPEF) score is a widely used diagnostic tool for heart failure with preserved ejection fraction (HFpEF). Angina symptoms are common in patients with HFpEF but are not included in the score. We aimed to determine whether incorporating angina into the H2FPEF score improves its diagnostic performance sex-specifically, given the well-known sex differences in both HFpEF and angina presentation.Methods We included 515 individuals from the UHFO-DM cohort with suspected HFpEF. Participants underwent standardised symptom collection, including angina using WHO questionnaires, and expert-panel adjudication of HFpEF. Following evaluation of H 2FPEF, we assessed the association of angina with HFpEF independent of H2FPEF using logistic regression. By adding angina to H2FPEF, we developed a modified algorithm and evaluated it by the area under the receiver operating characteristic curve (AUC), calibration, reclassification and decision curve analysis. All analyses were stratified by sex. We also included another 751 individuals with suspected HFpEF from a Combination cohort of UHFO-COPD (n=136), STRETCH (n=331) and TREE (n=284) for regression analysis.Results In the UHFO-DM cohort, HFpEF prevalence was 24%. Overall H 2FPEF discrimination (AUC) was 0.72, with 0.69 in women and 0.74 in men. Angina was independently associated with HFpEF in women (OR 3.96, 95% CI 1.72 to 9.11, p=0.001) but not in men (1.90, 0.88 to 4.10, 0.102). Adding one point for angina in a modified H2FPEF score in women improved AUC from 0.69 to 0.71 (DeLong p=0.030), increased sensitivity (0.53 to 0.60) and negative predictive value (0.80 to 0.82) and yielded a continuous net reclassification improvement of 0.449, with preserved calibration and higher net clinical benefit on decision curves. No performance gain was observed with the same modification in men. In the Combination cohort, angina was also independently associated with HFpEF only in women (women, 2.13, 1.14 to 3.97, 0.018; men, 0.85, 0.44 to 1.66, 0.638).Conclusions In women with suspected HFpEF, the presence of angina provides diagnostic information independent of H 2FPEF to uncover HFpEF. A simple sex-specific modification of H2FPEF, adding one point for angina in women, may slightly improve discrimination and rule-out performance in women.",
  "authors": [
    {
      "affiliations": [
        "Experimental Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Kaiyong Qu"
    },
    {
      "affiliations": [
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "N Charlotte Onland-Moret"
    },
    {
      "affiliations": [
        "Experimental Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Amber de Vos"
    },
    {
      "affiliations": [
        "Experimental Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Anne Margje Lisa Naomi van Ommen"
    },
    {
      "affiliations": [
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Yvonne van Mourik"
    },
    {
      "affiliations": [
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Evelien E van Riet"
    },
    {
      "affiliations": [
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Leandra Boonman - de Winter"
    },
    {
      "affiliations": [
        "Department of Cardiology, Amsterdam University Medical Centres, Amsterdam, The Netherlands"
      ],
      "name": "M L Handoko"
    },
    {
      "affiliations": [
        "Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands"
      ],
      "name": "Maarten Jan Cramer"
    },
    {
      "affiliations": [
        "Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands"
      ],
      "name": "Arco J Teske"
    },
    {
      "affiliations": [
        "Cardiology Centers of the Netherlands, Utrecht, Netherlands"
      ],
      "name": "Roxana Menken"
    },
    {
      "affiliations": [
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Frans Rutten"
    },
    {
      "affiliations": [
        "Experimental Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Hester M den Ruijter"
    },
    {
      "affiliations": [
        "Experimental Cardiology, University Medical Centre Utrecht, Utrecht, Netherlands",
        "Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, Netherlands"
      ],
      "name": "Elisa Dal Canto"
    }
  ],
  "title": "Incorporating angina into the H2FPEF score improves diagnostic performance for HFpEF in women",
  "uid": "fd042d03-d421-5ab5-8dbb-f67f35d6182e"
}