Impact of the 2025 ASE Guidelines on the Classification of LV Diastolic Dysfunction in the Community: A Project Baseline Health Study

BACKGROUND: The 2016 American Society of Echocardiography (ASE) guidelines for left ventricular diastolic dysfunction (LVDD) classification resulted in a significant proportion of indeterminate classifications and grades. To address these limitations and incorporate new evidence, the ASE updated its recommendations in 2025. The impact of these revisions in community cohorts remains unclear. METHODS: We studied 1953 Project Baseline Health Study participants who underwent comprehensive transthoracic echocardiography. LVDD was classified using the 2016 and 2025 ASE recommendations. For the 2025 recommendations, fixed and age-specific thresholds were evaluated separately. We compared LVDD prevalence, reclassification patterns, associations with cardiovascular risk factors, and prognostic value for major adverse cardiovascular events over a median follow-up of 4.3 years. RESULTS: Median patient age was 50.6 years (Q1–Q3: 36.3–64.2); 56.3% of patients were female, 35.3% had hypertension, and 14.2% had diabetes. The prevalence of LVDD was higher with the 2025 recommendations than with the 2016 algorithm: fixed criteria 308 (15.8%), age-specific criteria 220 (11.3%) versus ASE 2016 154 (8.0%). Among 119 (6.1%) participants classified as indeterminate by the 2016 algorithm, the 2025 recommendations reclassified 51.2% as no LVDD and 31.8% as Grade 2 LVDD. Participants reclassified as no LVDD had event-free survival that was not statistically different from those without LVDD ( P =0.26), whereas those reclassified as Grade 2 had higher event rates (12.5% versus 3.8%; P =0.02). Major adverse cardiovascular events occurred in 98 (5.0%) participants over the follow-up period. LVDD by all classification approaches was independently associated with major adverse cardiovascular events after adjustment for baseline risk factors. CONCLUSIONS: The 2025 ASE recommendations identified more participants with LVDD than the 2016 algorithm without indeterminate classification or grading. LVDD by the 2025 classification was significantly associated with major adverse cardiovascular events, supporting the clinical relevance of the revised framework.