The 2025 ASE diastolic guideline eliminated the indeterminate category and predicted 1-year heart failure hospitalization (HR 3.80; 95% CI 3.36-4.31) with similar discrimination to the 2016 algorithm.
Cohort (n=5,907)
Yes
Does the 2025 ASE diastolic guideline algorithm improve prognostic discrimination for 1-year HF hospitalization and all-cause mortality compared to the 2016 algorithm in patients undergoing echocardiography?
The 2025 ASE diastolic algorithm eliminates the indeterminate category while maintaining similar prognostic discrimination for 1-year HF hospitalization and mortality compared to the 2016 framework.
Effect estimate: HR 3.80 (95% CI 3.36-4.31)
BACKGROUND The 2025 American Society of Echocardiography (ASE) diastolic guideline updates the 2016 ASE/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 three U.S. 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 (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). CONCLUSIONS 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.
Hafez et al. (Sun,) conducted a cohort in Left Ventricular Diastolic Dysfunction (n=5,907). 2025 ASE diastolic guideline vs. 2016 ASE/EACVI algorithm was evaluated on 1-year heart failure hospitalization (HR 3.80, 95% CI 3.36-4.31). The 2025 ASE diastolic guideline eliminated the indeterminate category and predicted 1-year heart failure hospitalization (HR 3.80; 95% CI 3.36-4.31) with similar discrimination to the 2016 algorithm.