Incorporating angina into the H2FPEF score improves diagnostic performance for HFpEF in women

Qu K, Onland-Moret NC, de Vos A, van Ommen AMLN, van Mourik Y, van Riet EE, Boonman-de Winter L, Handoko ML, Cramer MJ, Teske AJ, Menken R, Rutten F, den Ruijter HM, Dal Canto E. Incorporating angina into the H₂FPEF score improves diagnostic performance for HFpEF in women. Open Heart. 2026 May 4;13(1):e004054. doi: 10.1136/openhrt-2026-004054. PMID: 42082374; PMCID: PMC13141154.

The H₂FPEF score is a commonly used diagnostic tool for heart failure with preserved ejection fraction, but it does not account for angina despite its frequent occurrence in affected patients. We investigated whether incorporating angina into the H₂FPEF score improves diagnostic performance, with particular attention to sex differences. Angina was independently associated with HFpEF in women but not in men, indicating that it provides additional diagnostic information beyond the existing score only in women. A simple modification that incorporates angina into the H₂FPEF score for women modestly improved diagnostic discrimination, enhanced the ability to rule out HFpEF, and maintained good calibration and clinical utility, whereas no improvement was observed in men. These findings were supported in an independent validation cohort, highlighting the potential value of a sex-specific approach to HFpEF diagnosis by incorporating angina into existing diagnostic algorithms.