My Approach to Echocardiographic Assessment of Left Ventricular Filling Pressures: From Ambiguity to Precision With New Guidelines

The echocardiographic estimation of left ventricular (LV) filling pressures is a cornerstone in the assessment of heart failure, particularly in patients with heart failure with preserved ejection fraction (HFpEF).The 2016 American Society of Echocardiography/European Association of cardiovascular Imaging algorithm standardized this evaluation using key variables, but a substantial proportion of cases remained indeterminate in clinical practice.The recent update of the American guideline reorganized the approach into a hierarchical framework, incorporating age-related adjustments and formalizing the role of left atrial strain (LAS) as a tie-breaking parameter, while also providing a more detailed characterization of special clinical scenarios.In parallel, the 2024 British Society of Echocardiography guideline emphasizes the pathophysiological interpretation of ventricular filling, complementing the operational framework proposed by the American document.Multicenter studies with invasive validation support these updates, establishing LAS as a robust marker of increased filling pressures.In this article, we present My Approach to echocardiographic assessment of LV filling pressures, based on an initial morphofunctional evaluation, followed by structured screening (Step 1) and further refinement (Step 2) incorporating LAS and additional parameters.We also provide a comparison between guidelines, discuss common pitfalls and algorithm limitations, and include case-based videos for practical application.