H2FPEF Score Calculator
Estimate HFpEF probability from BMI, antihypertensives, atrial fibrillation, age, E/e', and PASP.
What it does
Heart failure with preserved ejection fraction, or HFpEF, is hard to separate from other causes of breathlessness. The H2FPEF score was built for that exact problem: a patient with unexplained dyspnea and a normal ejection fraction, where the question is whether raised filling pressures are driving the symptoms.
The score uses six items that are available from the history, the medication list, and a standard echocardiogram. Obesity above a BMI of 30 earns 2 points. Treatment with two or more antihypertensive medicines earns 1. A history of atrial fibrillation earns 3, the largest single weight. Age above 60, an E/e' ratio above 9, and a pulmonary artery systolic pressure above 35 mm Hg each earn 1.
The total maps to three probability bands. A score of 0 or 1 means HFpEF is unlikely. A score of 2 to 5 is intermediate and usually calls for diastolic stress testing or invasive hemodynamics. A score of 6 to 9 means HFpEF is likely, and the diagnosis can often be made without further provocative testing if the clinical picture fits.
The original derivation and validation work came from patients referred for evaluation of exertional dyspnea. Later work showed that higher scores also track structural and hemodynamic changes in people without overt heart failure, which supports the score as a marker of risk rather than a stand-alone diagnosis.
The score does not include natriuretic peptide levels, left atrial volume, or exercise hemodynamics, so it can miss atypical cases. It also cannot separate HFpEF from other causes of high filling pressures, such as constrictive pericarditis or high-output states. Use it to organize the workup, then confirm with the tests the clinical setting requires.
How to use
- Choose metric or imperial units.
- Enter age, height, and weight so BMI can be computed.
- Mark whether there is any history of atrial fibrillation.
- Count the antihypertensive medicines the patient takes.
- Enter the mitral E/e' ratio and pulmonary artery systolic pressure from the echocardiogram.
- Read the total, probability band, BMI, and the points from each criterion.
Formula
- BMI
- Weight in kilograms divided by height in meters squared; above 30 scores 2 points.
- Antihypertensives
- Two or more medicines score 1 point; one or none score 0.
- Atrial fibrillation
- Any history of atrial fibrillation scores 3 points.
- Age
- Above 60 years scores 1 point.
- E/e'
- Mitral early velocity divided by tissue Doppler early velocity; above 9 scores 1 point.
- PASP
- Pulmonary artery systolic pressure in mm Hg; above 35 scores 1 point.
All cutoffs are strict. A BMI of exactly 30 does not score, an age of exactly 60 does not score, an E/e' of exactly 9 does not score, and a PASP of exactly 35 does not score. The three bands are 0 to 1 for low probability, 2 to 5 for intermediate, and 6 to 9 for high. The original paper also published a continuous model that gives a percentage, but the point score is the version used at the bedside.
Worked example
Example: age 67, BMI 32.0, atrial fibrillation, two medicines, E/e' 11, PASP 30
Age 67, height 170 cm, weight 92.5 kg, history of atrial fibrillation, two antihypertensive medicines, E/e' 11, PASP 30 mm Hg.
- BMI = 92.5 / (1.70 x 1.70) = 92.5 / 2.89 = 32.0, which is above 30, so obesity scores 2.
- Two or more antihypertensive medicines score 1.
- Atrial fibrillation scores 3.
- Age 67 is above 60, so age scores 1.
- E/e' 11 is above 9, so filling pressure scores 1.
- PASP 30 is not above 35, so pulmonary pressure scores 0.
- The total is 2 + 1 + 3 + 1 + 1 + 0 = 8, which is the high probability band (6 to 9).
Reference table
| Criterion | Threshold | Points |
|---|---|---|
| Obesity | BMI above 30 | 2 |
| Antihypertensive medicines | Two or more | 1 |
| Atrial fibrillation | Any history | 3 |
| Age | Above 60 years | 1 |
| Filling pressure | E/e' above 9 | 1 |
| Pulmonary pressure | PASP above 35 mm Hg | 1 |
Limits
- Built for patients with unexplained dyspnea, not as a general heart failure screening tool.
- Requires a transthoracic echocardiogram for E/e' and pulmonary artery systolic pressure.
- An intermediate score does not rule HFpEF in or out and often needs stress testing or catheterization.
- Does not account for natriuretic peptides, left atrial volume, or other causes of high filling pressures.
Common mistakes
- Scoring one antihypertensive medicine when the cutoff is two or more.
- Counting a BMI of exactly 30 as obesity.
- Scoring age 60 rather than age above 60.
- Using E/e' of exactly 9 as abnormal when the cutoff is above 9.
- Treating a high score as a diagnosis without checking for alternative causes.
Try it yourself
Quick checks. Answers sit tucked under each question.
Age 55, 165 cm, 63.5 kg, no atrial fibrillation, no antihypertensives, E/e' 8, PASP 30?
Score 0, low probability. BMI 23.3, and every criterion stays below its threshold.
Age 70, 170 cm, 89.6 kg, no atrial fibrillation, one antihypertensive, E/e' 10, PASP 40?
Score 5, intermediate probability. BMI 31.0 scores 2, age scores 1, E/e' scores 1, and PASP scores 1.
Age 50, 175 cm, 76.6 kg, atrial fibrillation, no antihypertensives, E/e' 7, PASP 28?
Score 3, intermediate probability. BMI 25.0 scores 0, and only atrial fibrillation adds 3.
Questions
What does H2FPEF stand for?
The letters stand for the six inputs: heavy (obesity), hypertension medicines, atrial fibrillation, pulmonary hypertension, elder age, and filling pressure.
What score means HFpEF is likely?
A score of 6 to 9 is the high probability band. Scores of 2 to 5 are intermediate, and 0 to 1 is low.
Why does atrial fibrillation carry 3 points?
It was one of the strongest predictors in the derivation model and often reflects left atrial disease that accompanies HFpEF.
Do I need an echocardiogram?
Yes. E/e' and pulmonary artery systolic pressure come from echocardiography, and BMI needs height and weight.
Can the score exclude HFpEF?
A low score makes it unlikely but does not exclude it. Atypical presentations may still need stress testing or invasive measurement.
Is there a continuous version?
Yes. The original paper published a continuous model that estimates probability from 0 to 100%. This page uses the 0 to 9 point score.
Sources
- Reddy et al., a simple evidence-based approach to diagnose HFpEF, Circulation 2018
- Koepp et al., H2FPEF score and preclinical HFpEF, Nature Cardiovascular Research 2022