HFpEF: Normal by Echo, Abnormal by Hemodynamics | JACC Baran

Hosts Mitsuaki Sawano, MD, and Satoshi Shoji, MD welcome Dr. Tomonari Harada, MD, PhD (Mayo Clinic / Gunma University) with commentary from Dr. Masaru Obokata, MD (Gunma University) to discuss their JACC study, “Echocardiographic Diastolic Function Grading in HFpEF: Testing the Updated 2025 ASE Criteria.” This investigation applies the newly updated 2025 ASE diastolic function grading algorithm to invasively confirmed HFpEF cohorts and examines how frequently patients may be classified as “Normal” or “Grade 1” despite established disease. Across compensated outpatient HFpEF, acute decompensated admissions, and external validation cohorts, the study highlights substantial false-negative classifications, limited discrimination from noncardiac dyspnea, and dynamic grade shifts with changes in congestion status. The episode explores the clinical implications: why diastolic grade alone should not be used to exclude HFpEF, how exercise criteria perform in real-world cohorts, and why integrating pre-test probability and HFpEF-specific frameworks remains essential in contemporary heart failure evaluation.