WATCH: Houston Methodist-Led Study Validates Improved Echocardiographic Algorithm for Estimating LV Filling Pressure

A new algorithm provides a more accurate method for estimating left ventricular filling pressure (LVFP) by echocardiography, according to a Houston Methodist Hospital-led validation study that should improve the evaluation of patients presenting with dyspnea and suspected heart failure.

The international, multicenter study, published recently in Circulation, describes a structured, stepwise algorithm designed to enhance noninvasive assessment of LVFP — a key factor in distinguishing cardiac from noncardiac causes of shortness of breath.

“Determining whether dyspnea is cardiac in origin is fundamental to management, yet it remains clinically challenging, particularly in busy emergency and inpatient settings,” said Dr. Sherif F. Nagueh, a Houston Methodist cardiologist and the study’s primary investigator.

He added that the study confirms that “we now have a more accurate and highly feasible method for estimating filling pressure.”

Elevated LV filling pressure reflects increased left atrial pressure that transmits backward into the pulmonary circulation, producing congestion and dyspnea — a defining feature of heart failure.

Although cardiac catheterization remains the gold standard for measuring intracardiac pressures, it is not practical for routine evaluation.

“If a definitive measurement is required, invasive hemodynamics provide that answer,” Dr. Nagueh said. “However, it is not feasible to perform catheterization in every patient presenting with shortness of breath.”

Reducing indeterminate results

The algorithm was validated in 951 patients across multiple national and international centers, including Houston Methodist’s DeBakey Heart & Vascular Center. Echocardiographic findings were compared directly with invasively measured filling pressures obtained during clinically indicated catheterization.

Only two patients were classified as indeterminate using the updated algorithm, compared with 38 under the 2016 ASE/EACVI guidelines (P<0.0001). Sensitivity, specificity and overall accuracy were each 86%, improving upon the 80% accuracy of the prior recommendations.

“One of the principal limitations of the earlier guidelines was the proportion of indeterminate studies,” Dr. Nagueh said. “The revised structure substantially reduces that uncertainty.”

The updated algorithm incorporates additional indices — including left atrial reservoir strain — applied in a defined sequence to improve feasibility and diagnostic yield.

Stronger performance in preserved EF

The improvement was most notable in patients with preserved ejection fraction (EF ≥50%), who comprised approximately three-quarters of the study population. In this group — where filling pressure assessment is often more difficult — the new algorithm significantly outperformed the 2016 approach.

Heart failure with preserved ejection fraction accounts for at least half of heart failure hospitalizations and frequently presents diagnostic ambiguity where ejection fraction is normal despite symptomatic congestion.

Additionally, in 663 patients with natriuretic peptide data available, echocardiographic estimation of LVFP provided superior classification compared with biomarkers alone and added incremental value when combined with B-type natriuretic peptide (BNP) or N-terminal pro-B-type natriuretic peptide levels.

Structured, practical design

The algorithm follows a two-step framework. The first step evaluates three widely obtainable parameters: mitral annular early diastolic velocity (e′), the E/e′ ratio and pulmonary artery systolic pressure. When these are concordant, LVFP can be readily estimated.

If discordant, the second step incorporates additional measures — including left atrial reservoir strain, isovolumic relaxation time, pulmonary vein flow and left atrial maximum volume index — to refine classification.

By reorganizing routinely acquired echocardiographic data into a structured sequence, the approach reduces ambiguity.

For clinicians, greater diagnostic certainty supports more targeted management.

“Elevated filling pressure favors intensification of decongestive therapy, whereas normal filling pressure prompts evaluation for alternative causes of dyspnea,” Dr. Nagueh explained.

Conducted in collaboration with leading international institutions, the study underscores Houston Methodist’s continued leadership in advancing evidence-based cardiovascular imaging and heart failure diagnostics.

“This study demonstrates how rigorous multicenter validation can translate into practical tools that improve patient care,” Dr. Nagueh said.

Next steps

Dr. Nagueh and colleagues are exploring integration of machine learning to further refine or automate the framework, but he emphasized that the algorithm is ready for immediate clinical use.

The new LVFP algorithm is one of several recommendations from the latest 2025 ASE Diastolic Function Guidelines for the evaluation of left ventricular diastolic function and the diagnosis of patients with heart failure and preserved ejection fraction (HFpEF).  

The release of the 2025 guidelines marks the third time Dr. Nagueh has chaired the LVFP guidelines committee for the American Society of Echocardiographers. He and Dr. Purvi Parwani will co-chair a session about the new recommendations at the upcoming American College of Cardiology Scientific Sessions in New Orleans on March 28, 2026.