Is it likely that the diastolic dysfunction has progressed to grade 2 or 3 in a patient with a recent E/A ratio of 0.6, E/e' ratio of less than 8, and mild ankle edema?

Your Echocardiographic Parameters Strongly Indicate Grade 1 Diastolic Dysfunction Without Progression

Based on your E/A ratio of 0.6 and E/e' ratio <8, you have Grade 1 diastolic dysfunction with normal left atrial pressures, and progression to Grade 2 or 3 is highly unlikely. 1

Why Your Parameters Rule Out Advanced Diastolic Dysfunction

Your echocardiographic findings definitively place you in Grade 1:

• E/A ratio of 0.6 indicates impaired relaxation pattern, which is the hallmark of Grade 1 diastolic dysfunction 1
• E/e' ratio <8 confirms normal left ventricular filling pressures, which excludes Grade 2 or 3 dysfunction 1
• Grade 2 requires E/e' >14, and Grade 3 requires E/A ≥2.0 with E/e' >14—neither of which you meet 1, 2

The Likelihood of Misgrading Is Extremely Low

Echocardiographers are very unlikely to mistake Grade 1 for Grades 2 or 3 because the parameters are distinctly different and move in opposite directions. 1

The grading system has built-in safeguards:

• Grade 1: E/A ≤0.8, E/e' <8, normal LA volume index (<34 mL/m²), TR velocity <2.8 m/sec 1, 2
• Grade 2: E/A 0.8-2.0, E/e' >14, LA volume index >34 mL/m², TR velocity >2.8 m/sec 1
• Grade 3: E/A ≥2.0, deceleration time <160 msec, E/e' >14, LA volume index >34 mL/m² 1

Your E/A ratio would need to increase from 0.6 to at least 2.0, and your E/e' would need to more than double to >14 for Grade 3—these are dramatic changes that cannot be missed 1

Your Symptoms Do Not Suggest Advanced Disease

Mild ankle edema alone, without dyspnea, orthopnea, or paroxysmal nocturnal dyspnea, does not indicate progression to Grade 2 or 3 diastolic dysfunction. 3

Key clinical distinctions:

• Grade 1 patients typically have minimal symptoms or mild peripheral edema, as the filling pressures remain normal or low 1, 2
• Grade 2-3 patients develop progressive dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, and more significant volume overload because of elevated left atrial pressures 1, 3
• Your mild ankle edema with CKD stage 3a and preserved ejection fraction more likely reflects renal sodium retention rather than cardiac decompensation 3

Additional Parameters That Would Signal Progression

If you were progressing to Grade 2 or 3, you would expect to see:

• Left atrial enlargement (LA volume index >34 mL/m²), which indicates chronically elevated filling pressures 1, 2
• Elevated tricuspid regurgitation velocity (>2.8 m/sec), suggesting elevated pulmonary pressures 1
• Shortened deceleration time (<160 msec) in Grade 3, indicating restrictive physiology 1
• Shortened IVRT (<50 msec) in advanced disease 1

Common Pitfalls to Avoid

The movement of E/A ratio toward "normal" (closer to 1.0) can paradoxically indicate either improvement OR progression to pseudonormal pattern (Grade 2). 4 This is why E/e' ratio and LA volume are critical—they distinguish true improvement from pseudonormalization. Your E/e' <8 confirms you remain in Grade 1 1

Do not confuse peripheral edema from CKD with cardiac decompensation. 3 In the absence of elevated filling pressures (your E/e' <8 confirms normal pressures), mild ankle edema is more attributable to renal dysfunction than cardiac dysfunction 3

What to Monitor Going Forward

Focus on parameters that indicate progression rather than attempting to document improvement in Grade 1 metrics:

• Serial assessment of LA volume index—enlargement >34 mL/m² would signal progression 1, 2, 4
• E/e' ratio trending upward toward >14 would indicate rising filling pressures 1
• Development of exertional dyspnea or orthopnea would warrant repeat echocardiography 4
• Blood pressure control is the primary modifiable factor to prevent progression 3, 4