Multicenter Invasive Validation of the 2025 ASE Versus 2016 ASE/EACVI Guidelines for the Assessment of Left Ventricular Filling Pressures

Abstract Background Accurate assessment of left ventricular filling pressures (LVFP) is critical for the diagnosis and management of diastolic dysfunction. The 2016 ASE/EACVI algorithm has been invaluable in routine practice, yet invasive studies have shown important gaps— especially in sensitivity. The 2025 ASE update brings revised thresholds, integrates and emphasizes left atrial strain, aiming to close these gaps and refine patient care. The clinical value of these changes compared to invasive hemodynamic measurements remains uncertain. Objectives This study represents an invasive, multicenter validation of the 2025 ASE diastolic function algorithm compared with the long-standing 2016 ASE/EACVI guidelines, using invasive left ventricular end-diastolic pressure (LVEDP) and LV pre-A pressure as the gold standard. Further objectives are to explore subgroup differences based on ejection fraction and sex, as well as, exploring 2-years readmission as an outcome for these guidelines. Methods Conducting a prospective invasive validation study including patients undergoing comprehensive echocardiography and left heart catheterization. LVEDP ≥ 16 mmHg or LV pre-A > 15 mmHg were defined as elevated filling pressures. Diastolic function was classified according to ASE 2025 and ASE/EACVI 2016 guidelines. Diagnostic accuracy, sensitivity, specificity, and area under the receiver operating characteristic (ROC) curve (AUC) were compared, with subgroup analyses for preserved/reduced EF and sex. Results A total of 492 patients were included. ASE 2025 demonstrated significantly higher sensitivity than ASE/EACVI 2016 for detecting elevated LVEDP (56.2% vs 22.2%, p<0.00001) and LV pre-A positivity (68.9% vs 25.7%, p<0.00001), while maintaining comparable specificity (for LV pre-A: 82.4%, for LVEDP: 92.6%). ASE 2025 achieved higher AUC values across all subgroups, particularly in preserved EF (0.754 vs 0.577 for LV pre-A) and female patients (0.756 vs 0.576 for LV pre-A). Agreement analysis showed moderate concordance between ASE 2025 and invasive measures (κ=0.46 for LVEDP, κ=0.51 for LV pre-A). In a 2-year follow-up, positive LAP classification by ASE 2025 was associated with higher odds of readmission (OR=3.1, p=0.0341) compared to ASE/EACVI 2016 (OR=2.5, p=0.037). Conclusions ASE 2025 guidelines provide improved sensitivity and overall diagnostic performance for detecting invasively confirmed elevated LVFP compared to ASE/EACVI 2016, this includes EF and gender subgroups. LAP assessment by ASE 2025 may predict 2-years readmission slightly better than ASE/EACVI 2016.