ArticleJournal of the American College of Cardiology2026
Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria.
Article in Journal of the American College of Cardiology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 11 papers.
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Who cites it
11 citing papers in PubMed.
- The LEDA Score: An Integrated Echocardiographic Score for the Diagnosis of HFpEF.JACC. Advances · 2026Article
- Comparison of Artificial Intelligence-Driven Echocardiographic Assessment of Diastolic Function With the ASE Guidelines.JACC. Advances · 2026Article
- Preserved and reduced ejection fraction manifest as two unique phenotypes of diastolic dysfunction-a mechanistic study.European heart journal. Imaging methods and practice · 2026Article
- Understanding HFpEF Through Imaging: Strengths, Limitations, and Current State of the Art.JACC. Cardiovascular imaging · 2026Review
- Concurrence of the Core Mechanistic Tenets of the American Heart Association Statement on the Cardiovascular-Kidney-Metabolic Syndrome and the Adipokine Hypothesis of Heart Failure With Preserved Ejection Fraction.Diabetes, obesity & metabolism · 2026Article
- Explainable machine learning for estimation of elevated left ventricular filling pressure: a multicenter validation.Journal of echocardiography · 2026Article
- Targeting TPO/MPL Signaling to Mitigate JAK2V617F-driven Cardiac Microvascular Disease.bioRxiv : the preprint server for biology · 2026Article
- Femoral Plaque Burden and Left Ventricular-Arterial Coupling in Patients with Chronic Heart Failure.Journal of clinical medicine · 2026Article
- Improvement of Heart Failure Discrimination by the Integration of the Left Ventricle Global Longitudinal Strain.Clinics and practice · 2026Article
- Linear dose-response relationship between TyG-WC index and diastolic dysfunction: insights from restricted cubic spline and machine learning analysis.Frontiers in endocrinology · 2026Article
- Multidimensional cardiac functional phenotyping beyond ejection fraction: a multimodality imaging framework for cardiovascular care.Frontiers in cardiovascular medicine · 2026Review
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19 authors.
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Abstract
backgroundEchocardiographic grading of left ventricular diastolic function is recommended to guide diagnostic evaluation of heart failure with preserved ejection fraction (HFpEF). A new algorithm for diastolic function interpretation has been proposed, but it has not yet been systematically evaluated in HFpEF.
objectivesThe purpose of this study was to determine the false-negative rate of the 2025 American Society of Echocardiography (ASE) algorithm among invasively confirmed ambulatory HFpEF, assess temporal changes in diastolic grades between decompensated and recompensated hospitalized HFpEF, and, secondarily, to compare diagnostic discrimination with existing HFpEF algorithms and prognostic associations.
methodsEchocardiography was performed in 2 HFpEF cohorts: 1) ambulatory, compensated patients undergoing invasive hemodynamic exercise testing as part of a prospective cohort study, with an external validation cohort; and 2) hospitalized/decompensated patients both acutely and following recompensation. For secondary analyses, we included noncardiac dyspnea controls and compared performance with existing algorithms.
resultsIn the ambulatory/compensated HFpEF cohort, 248 of 756 (32.8%) were graded normal, 263 of 756 (34.8%) had Grade 1 diastolic dysfunction, 219 of 756 (30.0%) had Grades 2 to 3, and 26 of 756 (3.4%) were indeterminate. Among those labeled normal or Grade 1, >60% had resting pulmonary artery wedge pressure ≥15 mm Hg at catheterization. In decompensated HFpEF, 22 of 88 (25.0%) showed normal or Grade 1, and this proportion increased to 45 of 88 (51.1%) after recompensation. In HFpEF with Grade 1 undergoing simultaneous hemodynamic exercise testing with stress imaging, only 11 of 116 (9.5%) met the ASE-recommended stress criteria, resulting in a 90.5% false-negative rate. Similar findings were observed in the external validation cohort. The 2025 ASE algorithm poorly discriminated HFpEF from noncardiac dyspnea (AUC: 0.61). Patients with HFpEF labeled as normal or Grade 1 had 5-fold higher risk for all-cause death or heart failure hospitalization compared with controls (HR: 5.37; 95% CI: 1.27-22.6).
conclusionsAmong patients with invasively proven HFpEF, the 2025 ASE algorithm frequently assigns normal or low diastolic grades, and the recommended stress criteria detect only a minority of cases. Although echocardiography remains essential to guide HFpEF evaluation, current algorithms proposed have inadequate sensitivity. Diastolic function grades must be interpreted in the context of pretest probability and HFpEF-specific, evidence-based frameworks, rather than used in isolation to exclude disease.
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