M.J.C. van den Berg1, R. Meer2, A. Uijl2,3,4,5, A.G. Hoek2, M. Hollander1, P.J.M. Elders1, 2, M.T. Blom1,2,4, J.W.J. Beulens2
1General Practice, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; 2 Epidemiology and Data Science, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; 3Department of Cardiology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.; 4Amsterdam Cardiovascular Sciences Research Institute, Amsterdam, The Netherlands; 5Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.
Background: Patients with type 2 diabetes (T2D) face a twofold increased risk of heart failure (HF), particularly HF with preserved ejection fraction (HFpEF). Prevalence rates of HFpEF are high in people with T2D, but vary due to diagnostic heterogeneity. This study compares HFpEF prevalence across commonly used definitions and examines echocardiographic abnormalities consistent with HFpEF in T2D patients in primary care.
Methods: We analyzed 844 T2D individuals without known HF from the Dutch Diabetes Care System cohort. Symptoms (e.g., exertional dyspnea, orthopnea, oedema) were assessed via questionnaires and physical exams. Transthoracic echocardiography and NT-proBNP measurements were performed. HFpEF prevalence was evaluated using four definitions: the European Society of Cardiology (ESC) guideline (2021), Dutch College of General Practitioners (NHG) guideline (2024), H2FPEF score (2020), and HFA-PEFF score (2019).
Results: In this cohort (37% female, median age 67 years [IQR: 62.8-71.0]), HFpEF prevalence was 37% under the ESC guideline, driven by a high prevalence (87%) of echocardiographic abnormality E/e′ >9. Raising the E/e′ threshold to >14 reduced ESC-HFpEF prevalence to 30%. ESC-HFpEF patients were more often female (49% vs. 31%) and had higher BMI (30.8 [IQR: 27.6-35.0] vs. 28.0 [IQR: 25.5-31.1]). HFpEF prevalence was 12% using NHG criteria. The H2FPEF and HFA-PEFF classifications resulted in 4% and 12% definitive HFpEF, with both scores classifying approximately 80% as intermediate HFpEF.
Conclusions: Substantial discrepancies in HFpEF prevalence were observed across the four algorithms. The HF2PEF and HFA-PEFF scores offered limited diagnostic clarity due to many intermediate classifications. In our population, the ESC guideline classified many participants as having HFpEF, higher E/e′ thresholds may improve discrimination in primary care. The NHG guideline identified fewer cases, which could reflect lower sensitivity. These findings suggest that reliance on echocardiographic parameters alone may be insufficient for accurate HFpEF diagnosis in primary care.