in normal hearts than with coronary disease and wall motion abnormalities, also explaining our high variability. However, the aim of our study was to reflect daily clinic, in which the abovementioned limitations are inevitable. Interestingly, new indexes of diastolic function seemed more reproducible compared to traditional (TR Vmax CV = 9.9-12 % vs. MV E and A CV = 12-20 %, LA volume CV = 19-22 % and E/e’ CV = 22-36 %). The overall moderate reproducibility found in our study is, however, not unique (31, 32).
The 2016 algorithm was superior at classifying patients compared to 2009 (Table 4a and 4b, appendix). This emphasises the dominance of an algorithm’s influence on grading, which can partly diminish the consequences of a high variability of the individual parameters.
Through reclassification analysis of the total (n=356) population, did the 2016 algorithm proved more restrictive than 2009 in classifying patients with advanced stages of DD (table 5). Other authors have reported similar decrease in the prevalence of DD by comparing the 2009 and 2016 algorithms (23, 33, 34). Elsewhere, the 2016 algorithm have likewise been shown superior to the 2009 in its ability to correlate with clinical outcome (35-37)
It is a natural chain of reasoning that a stronger reproducibility could have yielded improved re-classification. Therefore, the re-implementation of E/e’ average in the current guidelines (9) is striking in light of its considerable variability. We found the reproducibility of E/e’ average, most likely, is hampered by E/e’ lateral (intra- and inter-observer CV = 36 % and 45 % for E/e’ lateral vs. CV = 22 % and 23 % for E/e’ septal), suggesting replacement of E/e’ average with E/e’ septal. Further elaboration is needed for the optimal differentiation between normal and abnormal diastolic function and subsequent grading. Rather than more expert opinions there is a need for studies that relate novel classification schemes containing the most feasible, reproducible, time-efficient, and prognostic variables to clinical outcome.