Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria.
Summary
In invasively proven HFpEF, the 2025 ASE diastolic function algorithm frequently labeled patients as normal or Grade 1 despite elevated resting PAWP and showed poor sensitivity of its stress criteria (false-negative rate 90.5%). Discrimination versus noncardiac dyspnea was limited (AUC 0.61), indicating the algorithm should not be used in isolation to exclude HFpEF.
Key Findings
- Among ambulatory HFpEF, 32.8% graded normal and 34.8% Grade 1 despite invasive HFpEF; over 60% of normal/Grade 1 had resting PAWP ≥15 mm Hg.
- ASE-recommended stress criteria identified only 9.5% of Grade 1 cases (false-negative rate 90.5%).
- Discrimination vs noncardiac dyspnea was modest (AUC 0.61); patients labeled normal/Grade 1 had a 5.37-fold higher risk of death/HF hospitalization vs controls.
Clinical Implications
Do not rely solely on ASE 2025 diastolic grades to rule out HFpEF. Integrate pretest probability, invasive or exercise hemodynamics when appropriate, and HFpEF-specific diagnostic frameworks to avoid missed diagnoses.
Why It Matters
Challenges a newly proposed diagnostic standard with invasive reference, revealing substantial false negatives that could misclassify HFpEF. This is a practice-informing negative result likely to influence guideline interpretation and clinical workflows.
Limitations
- Observational diagnostic evaluation; not randomized or interventional.
- Generalizability may vary across labs and imaging protocols; algorithm-specific assessment.
Future Directions
Develop HFpEF-specific diagnostic pathways integrating exercise hemodynamics and machine-learning phenotyping; prospectively test patient-centered outcomes when using alternative frameworks.
Study Information
- Study Type
- Cohort
- Research Domain
- Diagnosis
- Evidence Level
- II - Prospective cohort with invasive gold standard and external validation
- Study Design
- OTHER