Reclassifying Left Ventricular Diastolic Function with the 2025 American Society of Echocardiography Guideline versus the 2016 Algorithm.

BACKGROUND

The 2025 American Society of Echocardiography (ASE) diastolic guideline updates the 2016 ASE/European Association of Cardiovascular Imaging (EACVI) algorithm by incorporating outcome-anchored thresholds and left atrial (LA) strain, which may alter diastolic grading and prognostic classification.

OBJECTIVES

To quantify reclassification between the 2016 and 2025 ASE diastolic algorithms and compare outcomes-based risk stratification for 1-year heart failure (HF) hospitalization and all-cause mortality across diastolic grades and filling-pressure categories.

METHODS

Using structured echocardiographic variables from Mayo Database Explorer pooled across 3 US Mayo Clinic sites, we applied both guidelines to the same index transthoracic echocardiogram. The analytic cohort required complete parameters to operationalize both algorithms on the same study and included only sinus-rhythm examinations. Reclassification was summarized using cross-tabulation and a Sankey diagram. Outcomes were 1 year HF hospitalization and 1 year all-cause mortality. Associations were evaluated with Kaplan-Meier methods and unadjusted Cox models; discrimination for HF hospitalization was quantified using the C-index for filling-pressure classification.

RESULTS

Of 20,000 screened index echocardiograms, sequential exclusions yielded 5,907 patients. Under the 2016 guideline, classifications were normal, 4,050 (68.6%); indeterminate, 1,111 (18.8%); grade 1, 204 (3.5%); grade 2, 400 (6.8%); and grade 3, 142 (2.4%). Under the 2025 guideline, classifications were normal, 4,219 (71.4%); grade 1, 546 (9.2%); grade 2, 931 (15.8%); and grade 3, 211 (3.6%), eliminating the indeterminate category. For HF hospitalization, 2025 high versus low filling pressure was associated with higher risk (hazard ratio [HR] = 3.80; 95% CI, 3.36-4.31; C-index 0.64), with comparable discrimination under the 2016 framework (HR = 5.73; 95% CI, 4.96-6.62; C-index 0.65). For mortality, high versus low filling pressure was also associated with increased risk in both frameworks (2025 HR = 1.88; 95% CI, 1.36-2.60; 2016 HR = 2.10; 95% CI, 1.39-3.18).

CONCLUSION

The 2025 ASE algorithm removes the indeterminate category and yields clear, stepwise risk stratification; however, overall prognostic discrimination for clinical outcomes using filling-pressure classification is similar to the 2016 framework.