Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria (JACC March 2026-2)-Article: Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria

Article: Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria

Pdf Summary

This JACC study evaluated the updated 2025 American Society of Echocardiography (ASE) algorithm for grading left ventricular diastolic function as a diagnostic tool for heart failure with preserved ejection fraction (HFpEF). Investigators applied the algorithm retrospectively to two HFpEF populations: (1) 756 ambulatory, compensated patients with invasively confirmed HFpEF by rest and/or exercise pulmonary artery wedge pressure (PAWP) criteria (with an external multicenter validation cohort), and (2) 88 hospitalized HFpEF patients studied during acute decompensation and again after recompensation. Secondary analyses compared diagnostic performance against noncardiac dyspnea controls and against common HFpEF diagnostic frameworks (ASE 2016, HFA‑PEFF, and H2FPEF), and assessed prognostic associations.<br /><br />In ambulatory, invasively proven HFpEF, the 2025 ASE algorithm frequently assigned low grades: 32.8% were labeled “normal” and 34.8% Grade 1 diastolic dysfunction (DD), meaning about two-thirds were categorized as having normal resting filling pressures. However, among those labeled normal or Grade 1, ~60% actually had elevated resting PAWP (≥15 mm Hg) on catheterization. In hospitalized HFpEF, 25% still appeared normal/Grade 1 during decompensation, and after recompensation this rose to 51%, demonstrating strong load/congestion dependence of grading.<br /><br />The ASE-recommended exercise stress echo criteria for Grade 1 DD (exercise E/e′ elevation plus TR velocity ≥3.2 m/s) were highly insensitive: only 9.5% of invasively proven HFpEF cases met the stress criteria (false-negative rate 90.5%), with similar findings in the external cohort.<br /><br />Overall discrimination of HFpEF vs noncardiac dyspnea was poor for ASE 2025 (AUC ~0.61 at rest; ~0.63 with stress), and inferior to HFpEF-specific approaches. Importantly, HFpEF patients labeled normal/Grade 1 still had markedly worse outcomes than controls (≈5-fold higher risk of death or HF hospitalization). The authors conclude diastolic grades and current ASE stress thresholds should not be used in isolation to exclude HFpEF; interpretation must incorporate pretest probability and HFpEF-specific diagnostic frameworks.

Keywords

JACC study

2025 ASE algorithm

left ventricular diastolic function grading

HFpEF diagnosis

invasive hemodynamics

pulmonary artery wedge pressure (PAWP)

exercise stress echocardiography

E/e′ ratio

tricuspid regurgitation velocity

HFA-PEFF and H2FPEF comparison