European Radiology

, Volume 30, Issue 1, pp 630–639 | Cite as

Application of the newest European Association of Cardiovascular Imaging Recommendation regarding the long-term prognostic relevance of left ventricular diastolic function in heart failure with preserved ejection fraction

  • Ting-Tse Lin
  • Yi-Chih Wang
  • Jyh-Ming Jimmy Juang
  • Juey-Jen Hwang
  • Cho-Kai WuEmail author



The long-term predictive value of the new proposed algorithm in the updated 2016 guidelines of the European Association of Cardiovascular Imaging to assess diastolic dysfunction (DD) in patients with heart failure with preserved ejection fraction (HFpEF) has not been validated.


The analysis included 451 patients who were diagnosed with HFpEF as confirmed via echocardiography. The endpoints were mortality and hospitalization for HF. The Kaplan–Meier curves and Cox regression models were generated to determine the risk of all-cause mortality based on the 2016 and 2009 DD grading algorithm, respectively. We evaluated the net reclassification index of outcomes on the basis of 2009 DD grade after abiding by the 2016 recommendations.


After a follow-up of 2976 days, 119 patients (26.4%) died. According to the 2016 DD grading, grade III DD was associated with a significantly higher risk of mortality (hazard ratio [HR], 2.209; 95% CI 1.144–4.266) and HF hospitalization (HR, 2.047; 95% CI 1.348–3.870), as compared with grade I DD. Grade II DD was also associated with a higher risk of mortality (HR, 1.538; 95% CI 1.313–1.924). However, only grade III DD was independently associated with worse mortality based on 2009 DD grading. The net reclassification index for mortality increased significantly after grading by 2016 algorithm (10.6%, p < 0.001).


The 2016 DD grading algorithm showed improved prognostic value of long-term mortality in patients with HFpEF. Based on the findings of the study, the appropriate grading of DD is important in the prognostication of patients with HFpEF.

Key Points

• The application of the 2016 European Association of Cardiovascular Imaging recommendations diastolic dysfunction (DD) grading algorithm improves the predictive value for mortality.

• Our analysis suggests DD grades II and III based on 2016 guidelines is associated with poor outcomes as compared with grade I. The echocardiographic indices of the new algorithm should be obtained and applied to effectively evaluate DD.


Left-sided heart failure Transthoracic echocardiography Mortality 



Angiotensin-converting enzyme inhibitors


Angiotensin II receptor blockers


American Society of Echocardiography


Calcium channel blockers


Confidence interval


Diastolic dysfunction


European Association of Cardiovascular Imaging


Heart failure with preserved ejection fraction


Hazard ratio


Irbesartan in Heart Failure With Preserved Ejection Fraction


Left atrial pressure


Left atrium volume index


Left ventricular diastolic dysfunction


Major cardiovascular events


New York Heart Association


Pulmonary capillary wedge pressure


Receiver operating characteristic


Right ventricular


Systolic heart failure


Taiwan Diastolic Heart Failure Registry


Tricuspid regurgitation


Tricuspid regurgitation pressure gradient



This work was supported, in part, by the IBMS CRC Research Program of Institute of Biomedical Science, Academia Sinica (IBMS-CRC99-P02), and grants (NSC 99-2314-B-002-131-MY3, NSC 100-2341-B-002-160-) from the National Science Council of R.O.C.

Compliance with ethical standards


The scientific guarantor of this publication is Dr. Cho-Kai Wu.

Conflict of interest

The authors of this manuscript declare no relationships with any companies, whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all subjects (patients) in this study.

Ethical approval

Institutional Review Board approval was obtained.


• Prospective

• Observational

• Performed at one institution

Supplementary material

330_2019_6261_MOESM1_ESM.docx (24 kb)
ESM 1 (DOCX 23 kb)


  1. 1.
    Owan TE, Hodge DO, Herges RM, Jacobsen SJ, Roger VL, Redfield MM (2006) Trends in prevalence and outcome of heart failure with preserved ejection fraction. N Engl J Med 355:251–259CrossRefGoogle Scholar
  2. 2.
    Zile MR (2003) Heart failure with preserved ejection fraction: is this diastolic heart failure? J Am Coll Cardiol 41:1519–1522CrossRefGoogle Scholar
  3. 3.
    Wu CK, Lee JK, Chiang FT et al (2014) Prognostic factors of heart failure with preserved ejection fraction: a 12-year prospective cohort follow-up study. Int J Cardiol 171:331–337CrossRefGoogle Scholar
  4. 4.
    Vasan RS, Larson MG, Benjamin EJ, Evans JC, Reiss CK, Levy D (1999) Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction: prevalence and mortality in a population-based cohort. J Am Coll Cardiol 33:1948–1955CrossRefGoogle Scholar
  5. 5.
    Nagueh SF, Appleton CP, Gillebert TC et al (2009) Recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 22:107–133. CrossRefPubMedGoogle Scholar
  6. 6.
    Paulus WJ, Tschope C, Sanderson JE et al (2007) How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology. Eur Heart J 28:2539–2550CrossRefGoogle Scholar
  7. 7.
    Redfield MM, Jacobsen SJ, Burnett JC Jr, Mahoney DW, Bailey KR, Rodeheffer RJ (2003) Burden of systolic and diastolic ventricular dysfunction in the community: appreciating the scope of the heart failure epidemic. JAMA 289:194–202CrossRefGoogle Scholar
  8. 8.
    Halley CM, Houghtaling PL, Khalil MK, Thomas JD, Jaber WA (2011) Mortality rate in patients with diastolic dysfunction and normal systolic function. Arch Intern Med 171:1082–1087. CrossRefPubMedGoogle Scholar
  9. 9.
    Melenovsky V, Hwang SJ, Lin G, Redfield MM, Borlaug BA (2014) Right heart dysfunction in heart failure with preserved ejection fraction. Eur Heart J 35:3452–3462. CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Nagueh SF, Smiseth OA, Appleton CP et al (2016) Recommendations for the evaluation of left ventricular diastolic function by echocardiography: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 29:277–314. CrossRefPubMedGoogle Scholar
  11. 11.
    Wu CK, Wang YC, Lee JK et al (2014) Connective tissue growth factor and cardiac diastolic dysfunction: human data from the Taiwan diastolic heart failure registry and molecular basis by cellular and animal models. Eur J Heart Fail 16:163–172CrossRefGoogle Scholar
  12. 12.
    Pencina MJ, D'Agostino RB Sr, D'Agostino RB Jr, Vasan RS (2008) Evaluating the added predictive ability of a new marker: from area under the ROC curve to reclassification and beyond. Stat Med 27:157–172 discussion 207-112CrossRefGoogle Scholar
  13. 13.
    Newson RB (2010) Comparing the predictive powers of survival models using Harrell’s C or Somers’ D. Stata J 10:339–358CrossRefGoogle Scholar
  14. 14.
    Komajda M, Carson PE, Hetzel S et al (2011) Factors associated with outcome in heart failure with preserved ejection fraction: findings from the Irbesartan in Heart Failure with Preserved Ejection Fraction Study (I-PRESERVE). Circ Heart Fail 4:27–35CrossRefGoogle Scholar
  15. 15.
    Zile MR, Gottdiener JS, Hetzel SJ et al (2011) Prevalence and significance of alterations in cardiac structure and function in patients with heart failure and a preserved ejection fraction. Circulation 124:2491–2501CrossRefGoogle Scholar
  16. 16.
    Bella JN, Palmieri V, Roman MJ et al (2002) Mitral ratio of peak early to late diastolic filling velocity as a predictor of mortality in middle-aged and elderly adults: the Strong Heart Study. Circulation 105:1928–1933. CrossRefPubMedGoogle Scholar
  17. 17.
    Persson H, Lonn E, Edner M et al (2007) Diastolic dysfunction in heart failure with preserved systolic function: need for objective evidence: results from the CHARM Echocardiographic Substudy-CHARMES. J Am Coll Cardiol 49:687–694CrossRefGoogle Scholar
  18. 18.
    Aljaroudi W, Alraies MC, Halley C et al (2012) Impact of progression of diastolic dysfunction on mortality in patients with normal ejection fraction. Circulation 125:782–788. CrossRefPubMedGoogle Scholar
  19. 19.
    Jones RC, Francis GS, Lauer MS (2004) Predictors of mortality in patients with heart failure and preserved systolic function in the Digitalis Investigation Group trial. J Am Coll Cardiol 44:1025–1029CrossRefGoogle Scholar
  20. 20.
    Bouchard JL, Aurigemma GP, Hill JC, Ennis CA, Tighe DA (2008) Usefulness of the pulmonary arterial systolic pressure to predict pulmonary arterial wedge pressure in patients with normal left ventricular systolic function. Am J Cardiol 101:1673–1676. CrossRefPubMedGoogle Scholar
  21. 21.
    Lam CS, Roger VL, Rodeheffer RJ, Borlaug BA, Enders FT, Redfield MM (2009) Pulmonary hypertension in heart failure with preserved ejection fraction: a community-based study. J Am Coll Cardiol 53:1119–1126. CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Mohammed SF, Hussain I, AbouEzzeddine OF et al (2014) Right ventricular function in heart failure with preserved ejection fraction: a community-based study. Circulation 130:2310–2320. CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Guazzi M, Dixon D, Labate V et al (2017) RV contractile function and its coupling to pulmonary circulation in heart failure with preserved ejection fraction: stratification of clinical phenotypes and outcomes. JACC Cardiovasc Imaging 10:1211–1221. CrossRefPubMedGoogle Scholar
  24. 24.
    Mascherbauer J, Zotter-Tufaro C, Duca F et al (2017) Wedge pressure rather than left ventricular end-diastolic pressure predicts outcome in heart failure with preserved ejection fraction. JACC Heart Fail 5:795–801. CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Lancellotti P, Galderisi M, Edvardsen T et al (2017) Echo-Doppler estimation of left ventricular filling pressure: results of the multicentre EACVI Euro-Filling study. Eur Heart J Cardiovasc Imaging 18:961–968. CrossRefPubMedGoogle Scholar
  26. 26.
    Balaney B, Medvedofsky D, Mediratta A et al (2018) Invasive validation of the echocardiographic assessment of left ventricular filling pressures using the 2016 diastolic guidelines: head-to-head comparison with the 2009 guidelines. J Am Soc Echocardiogr 31:79–88. CrossRefPubMedGoogle Scholar
  27. 27.
    Almeida JG, Fontes-Carvalho R, Sampaio F et al (2018) Impact of the 2016 ASE/EACVI recommendations on the prevalence of diastolic dysfunction in the general population. Eur Heart J Cardiovasc Imaging 19:380–386. CrossRefPubMedGoogle Scholar
  28. 28.
    Sanchis L, Andrea R, Falces C, Poyatos S, Vidal B, Sitges M (2018) Differential clinical implications of current recommendations for the evaluation of left ventricular diastolic function by echocardiography. J Am Soc Echocardiogr 31:1203–1208. CrossRefPubMedGoogle Scholar
  29. 29.
    Wu CK, Su MY, Lee JK et al (2015) Galectin-3 level and the severity of cardiac diastolic dysfunction using cellular and animal models and clinical indices. Sci Rep 5:17007.
  30. 30.
    Wu CK, Lee JK, Chiang FT et al (2011) Plasma levels of tumor necrosis factor-α and interleukin-6 are associated with diastolic heart failure through downregulation of sarcoplasmic reticulum Ca2+ ATPase. Crit Care Med 39:984–992. CrossRefGoogle Scholar
  31. 31.
    Wu CK, Tsai HY, Su MM et al (2017) Evolutional change in epicardial fat and its correlation with myocardial diffuse fibrosis in heart failure patients. J Clin Lipidol 11:1421–1431. CrossRefGoogle Scholar

Copyright information

© European Society of Radiology 2019

Authors and Affiliations

  1. 1.Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and Hospital Hsin-Chu BranchHsin-Chu CityTaiwan
  2. 2.Division of Cardiology, Department of Internal MedicineNational Taiwan University College of Medicine and HospitalTaipeiTaiwan

Personalised recommendations