Abstract
OBJECTIVE: Heart failure with preserved ejection fraction (HFpEF) is a growing clinical burden worldwide, yet diagnosis remains difficult due to phenotypic heterogeneity and the lack of a gold standard. Two algorithms-H(2)FPEF (Heavy, Hypertensive, Atrial Fibrillation, Pulmonary Hypertension, Elder, and Filling Pressure score) and the Heart Failure Association Pre-test Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, Final Etiology (HFA-PEFF)-have been developed to aid diagnosis, but evidence indicates substantial discordance. Moreover, neither incorporates social determinants of health (SDoH), which may contribute to inequities. MATERIALS AND METHODS: We conducted a systematic review following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to identify studies comparing the H(2)FPEF and HFA-PEFF algorithms within the same patient cohorts. Searches were performed in PubMed, Embase, Scopus, and Web of Science. Eligible studies reported diagnostic discordance or comparative performance. Narrative synthesis was applied, and methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Ten studies including 4,532 participants were reviewed. Discordance between algorithms ranged from 28% to 41%. H(2)FPEF demonstrated greater sensitivity, whereas HFA-PEFF showed higher specificity, but both achieved only moderate diagnostic accuracy. None of the studies incorporated SDoH variables, despite their established influence on heart failure diagnosis. CONCLUSION: Marked diagnostic discordance exists between H(2)FPEF and HFA-PEFF, underscoring the limitations of current tools. Excluding SDoH risks perpetuating disparities in HFpEF recognition and care. Future diagnostic frameworks should integrate both clinical and social variables. Explainable artificial intelligence, particularly machine learning models trained on multimodal data that include SDoH, offers a promising avenue toward more equitable, data-driven diagnosis of HFpEF.