Comparative Validation of BSE and EACVI/ASE Guidelines for Estimating Filling Pressure: Proposal of an Algorithm

Abstract Background Accurate noninvasive assessment of left ventricular (LV) filling pressure is pivotal in evaluating diastolic function. While both the EACVI/ASE 2016 and BSE 2024 guidelines provide structured echocardiographic criteria, their diagnostic agreement and alignment with invasive measurements remain unclear. Objectives To compare the diagnostic performance of BSE 2024 versus EACVI/ASE 2016 guidelines against invasively measured LV end-diastolic pressure (LVEDP) and LV pre-A pressure, and to propose and validate a complementary diagnostic algorithm to EACVI/ASE 2016 incorporating left atrial strain and pulmonary venous flow. Methods This prospective, multicenter study included 138 patients referred for elective left heart catheterization. Echocardiographic diastolic function was classified using both guideline systems. A novel complementary algorithm integrating LA reservoir strain (LARs), pulmonary venous S/D ratio, and Ar-A duration was evaluated. All classifications were validated against invasive hemodynamic data. Results BSE 2024 reduced indeterminate classifications (0.7%) but overclassified diastolic dysfunction (90.6%) compared with EACVI/ASE 2016 (39.9%). Both guidelines showed moderate agreement with invasive standards (AUC < 0.70). The proposed algorithm demonstrated superior diagnostic accuracy (AUC up to 0.82). No statistically difference between both guidelines for the assessment of EF preserved/reduced. Conclusions While BSE 2024 improves classification clarity, both guidelines show limited diagnostic accuracy compared to invasive measurements. A complementary algorithm based on EACVI/ASE 2016—enhanced by LARs and pulmonary venous flow—achieves significantly better performance and may guide future diagnostic strategies.