ASE/EACVI Echo Guidelines for Left Ventricular Diastolic Dysfunction
Core Diagnostic Algorithm
The 2016 ASE/EACVI guidelines recommend a structured, four-parameter approach to diagnose and grade LV diastolic dysfunction using echocardiography, with specific cutoff values that differ based on whether ejection fraction is reduced or preserved. 1
Essential Parameters to Measure
Primary Variables (Measure These Four First)
Mitral annular e' velocity 1, 2
- Septal e' < 7 cm/sec = abnormal
- Lateral e' < 10 cm/sec = abnormal
- Use tissue Doppler imaging at mitral annulus
- Average E/e' > 14 = elevated filling pressures
- Septal E/e' > 15 can be used if only septal measurement available
34 mL/m² = chronically elevated filling pressures
- Measure using biplane method of disks or area-length method
Peak TR velocity 1
2.8 m/sec = elevated pulmonary artery systolic pressure
- Obtain from multiple windows using continuous-wave Doppler
Supporting Variables
- Mitral inflow E and A velocities with E/A ratio 1, 2
- Deceleration time (DT) of mitral E velocity 2
- Pulmonary vein flow (S/D ratio < 1 supports elevated LAP) 1
Grading Algorithm for Reduced Ejection Fraction
Step 1: Evaluate Mitral Inflow Pattern 1
If E/A ≤ 0.8 AND peak E ≤ 50 cm/sec:
If E/A ≤ 0.8 AND peak E > 50 cm/sec, OR if E/A is 0.8-2.0:
- Proceed to Step 2 1
If E/A ≥ 2.0 AND DT < 160 msec:
- Grade III (restrictive) diastolic dysfunction 2
- LAP is elevated
- No further parameters needed
Step 2: Apply Three-Parameter Rule 1
Evaluate: E/e' ratio, LA volume index, and TR velocity
- If ≥2 of 3 parameters meet cutoffs: Grade II diastolic dysfunction with elevated LAP 1, 2
- If only 1 of 3 parameters meets cutoffs: Grade I diastolic dysfunction with normal LAP 1
- If only 1-2 parameters available and discordant: Do not report LAP or grade 1
Grading Algorithm for Preserved Ejection Fraction
Step 1: Assess Structural Abnormalities 1
Look for:
- LV hypertrophy (pathologic LV mass exceeding gender-specific norms) 1
- LA enlargement (clearly larger than RA in apical 4-chamber view) 1
- Elevated PASP from TR jet 1
These findings strongly suggest diastolic dysfunction even before Doppler assessment 1
Step 2: Evaluate Mitral Inflow 1
If E/A ≤ 0.8 AND peak E ≤ 50 cm/sec:
If E/A ≤ 0.8 AND peak E > 50 cm/sec, OR if E/A is 0.8-2.0:
- Measure all four primary parameters 1
- Apply same three-parameter rule as HFrEF (using E/e', LA volume, TR velocity) 1
If E/A ≥ 2.0:
- Grade III diastolic dysfunction 2
- Confirm with DT < 160 msec, E/e' > 14, LA volume > 34 mL/m², TR velocity > 2.8 m/sec 2
Step 3: Consider LV Global Longitudinal Strain 1
If diastolic parameters are inconclusive:
- Impaired GLS (reduced absolute value) plus reduced s' velocity indicates myocardial dysfunction 1
- This supports presence of diastolic dysfunction in patients with preserved EF 1
Diastolic Stress Testing
Indications 1
Perform when:
- Resting echo does not explain dyspnea or heart failure symptoms 1
- Patient has structural heart disease but borderline resting parameters 1
Do NOT perform if:
- Septal e' > 7 cm/sec AND lateral e' > 10 cm/sec at rest (normal diastolic function unlikely to deteriorate) 1
Protocol 1
- Measure mitral E velocity, e' velocity, E/e' ratio, and TR velocity at rest 1
- Perform treadmill or bicycle exercise 1
- Repeat measurements during exercise or 1-2 minutes post-exercise 1
Positive Test Criteria (All Three Must Be Present) 1
- Average E/e' > 14 (or septal E/e' > 15) during exercise 1
- Peak TR velocity > 2.8 m/sec during exercise 1
- Septal e' velocity < 7 cm/sec during exercise 1
Technical Acquisition Standards
Mitral Inflow 1, 2
- Apical 4-chamber view with pulsed-wave Doppler 1, 2
- Sample volume at mitral leaflet tips 1
- Sweep speed 100 mm/sec 1
- Low wall filter (100-200 MHz) and low gain 2
Tissue Doppler e' Velocity 1, 2
- Apical 4-chamber view 1, 2
- Sample volume at septal and lateral mitral annulus 1
- Optimize gain and filter settings to avoid high gain 1
- Sweep speed 100 mm/sec 1
LA Volume Index 1
- Measure at end-systole (just before mitral valve opening) 1
- Biplane method of disks or area-length method 1, 2
- Index to body surface area 1
Critical Pitfalls to Avoid
Arrhythmias and Conduction Abnormalities 1
- First-degree AV block: Parameters remain valid if E and A velocities do not fuse 1
- If mitral velocity at onset of A > 20 cm/sec: Subtract this from peak A velocity to avoid misclassifying as impaired relaxation 1
- Left bundle branch block, RV pacing, CRT: E/e' ratio accuracy is reduced 1
- Atrial fibrillation: Average 5-10 consecutive beats; A velocity and pulmonary vein atrial reversal cannot be assessed 1
Age-Related Changes 1
- E velocity decreases with age 1
- A velocity increases with age 1
- E/A ratio has U-shaped relationship with diastolic function, making pseudonormal pattern difficult to distinguish from normal in middle-aged patients 1
Loading Conditions 1
- Mitral E velocity is highly preload-dependent 1
- Consider Valsalva maneuver if pseudonormal pattern suspected: decrease in E/A to ≤ 0.8 confirms elevated LAP 1
Structural Heart Disease 1
- Mitral stenosis, mitral regurgitation, prosthetic mitral valve: Mitral inflow parameters invalid 1
- HCM: Use average E/e' > 14, LA volume > 34 mL/m², pulmonary vein AR duration ≥30 msec longer than mitral A duration, TR velocity > 2.8 m/sec 2
Prognostic Implications
Heart Failure with Reduced EF 1
- Restrictive filling pattern (E/A ≥ 2, DT < 160 msec) predicts worse outcomes independent of LVEF 1
- E/e' ratio correlates with functional class and prognosis better than LVEF alone 1
Heart Failure with Preserved EF 1
- LV hypertrophy, septal E/e' ratio, and TR velocity predict outcomes beyond clinical characteristics 1
- LA size and LV mass independently associated with increased morbidity and mortality 1
- RV dysfunction provides prognostic information independent of PASP 1
- Advanced diastolic dysfunction (grades II-III) independently predicts 24% increase in 5-year mortality among hospitalized patients 4
Novel and Emerging Parameters
Strain Imaging 1
- LV global longitudinal diastolic strain rate during isovolumic relaxation and early diastole correlates with time constant of LV relaxation 1
- Delayed peak LV untwisting rate helps diagnose diastolic dysfunction in patients with normal volumes and EF 1
- LA systolic strain inversely correlates with mean wedge pressure, though technical limitations exist 1
These parameters show promise for predicting outcomes but require significant experience and are not yet part of routine clinical algorithms 1