An evidence-based tool for screening for heart failure with preserved ejection fraction in primary care: The BREATH₂ score

Background: Heart failure with preserved ejection fraction (HFpEF) remains underdiagnosed in primary care settings, where echocardiography is not available. This study aimed to develop and validate a scoring system that does not include echocardiographic variables for HFpEF screening among patients with shortness of breath. Methods: A total of 622 consecutive patients referred for exercise stress echocardiography were evaluated (283 HFpEF and 339 controls). Diagnosis of HFpEF was determined by the HFA-PEFF algorithm Steps 2–3. Results: Multivariable logistic regression analysis identified age ≥65 years, coronary artery disease, elevated natriuretic peptide levels, anemia, cardiomegaly on chest radiography, and left ventricular high-voltage on electrocardiogram as independent predictors of having HFpEF. A weighted score, including the six predictors and atrial fibrillation, was created (BREATH₂ score). The BREATH₂ score accurately discriminated HFpEF from controls [area under the curve (AUC) 0.84, p < 0.0001], with a superior diagnostic ability to the H₂FPEF score. The diagnostic accuracy was confirmed in an external validation cohort (n = 105, AUC 0.78, p < 0.0001) and in patients whose diagnosis was determined by exercise right heart catheterization (n = 79, AUC 0.75, p = 0.0001). The BREATH₂ score classified each patient into different risk categories of having HFpEF, ranging from 4 % to 93 %. Conclusions: The BREATH₂ score can be an effective screening tool in primary care settings to help refer patients to a secondary hospital for further evaluation.