In a middle‑aged/older adult with a normal‑sized left ventricle, ejection fraction 60‑65%, grade II pseudonormal diastolic dysfunction, moderately dilated left atrium, mild aortic, mitral and tricuspid valve disease, and normal right‑ventricular systolic pressure, what is the echocardiographic interpretation and recommended management?

Echocardiographic Interpretation and Management

This patient has grade II diastolic dysfunction with elevated left ventricular filling pressures, requiring aggressive blood pressure control and close monitoring for symptom development, but does not need heart failure medications unless symptoms emerge. 1

Echocardiographic Interpretation

Grade II (Pseudonormal) Diastolic Dysfunction with Elevated Filling Pressures

The combination of grade II diastolic dysfunction and moderately dilated left atrium confirms chronically elevated left ventricular filling pressures. 2 Key diagnostic features present in this case:

• Moderately dilated left atrium - This is strongly suggestive of chronically elevated LV filling pressure in the setting of preserved ejection fraction, provided mitral valve disease, atrial arrhythmias, and anemia are excluded. 2
• Normal right ventricular systolic pressure (RVSP 26 mmHg) - The TR jet velocity is below the 2.8 m/sec threshold (approximately 2.5 m/sec based on RVSP calculation), which does not support markedly elevated pulmonary pressures at rest. 2
• Preserved systolic function (EF 60-65%) - In patients with preserved EF, multiple structural and functional parameters are needed to assess diastolic function, not just transmitral flow patterns. 2

Mild Valvular Disease

The mild aortic regurgitation, mitral regurgitation, and tricuspid regurgitation with associated valve sclerosis and calcification represent age-related degenerative changes that do not require intervention at this stage. 2 These mild lesions do not significantly contribute to the left atrial dilatation, which is primarily driven by the diastolic dysfunction. 2

Primary Care Management Strategy

Blood Pressure Control is the Cornerstone

Target aggressive blood pressure control, as this is the single most important modifiable factor in managing grade II diastolic dysfunction. 1 This patient represents the typical demographic (middle-aged/older adult) where hypertension is the primary driver. 1

Do NOT initiate heart failure medications in the absence of symptoms - The American College of Cardiology explicitly states there is no proven benefit from pharmacologic therapy (diuretics, nitrates, ACE inhibitors for heart failure indication) in asymptomatic diastolic dysfunction, and aggressive diuretic use may actually reduce cardiac output. 1

Surveillance Protocol

• Clinical assessment every 6 months to detect symptom onset (dyspnea, exercise intolerance, orthopnea, paroxysmal nocturnal dyspnea). 1
• Repeat echocardiography in 12 months to monitor for progression, given the grade II dysfunction with borderline features. 2, 1
• Instruct the patient to report immediately any change in functional status, as symptom development fundamentally changes the management approach. 2

When to Refer to Cardiology

Immediate referral is NOT required for this asymptomatic patient with grade II diastolic dysfunction and normal pulmonary pressures. 1 However, refer if any of the following develop:

• Symptoms emerge - Dyspnea, exercise intolerance, or pulmonary congestion despite optimized blood pressure control. 1
• Progression to grade III - Restrictive filling pattern (E/A ratio >2.5, DT <150 msec), which carries significantly worse prognosis. 1, 3
• Marked LA enlargement - LA volume index >50 mL/m² suggesting severe chronically elevated filling pressures. 1
• Elevated pulmonary pressures develop - TR jet velocity >2.8 m/sec on follow-up studies. 1
• Coexisting significant valvular disease progresses beyond mild severity. 1

Critical Clinical Pitfalls to Avoid

Do not misinterpret the "pseudonormal" pattern - Grade II diastolic dysfunction can appear deceptively normal on transmitral flow Doppler because elevated left atrial pressure normalizes the E/A ratio. 4 This is why the moderately dilated left atrium is such a critical finding - it confirms the chronicity of elevated filling pressures. 2, 5

Recognize that grade II represents moderate disease with disease progression - This is not early-stage dysfunction; it indicates the LA has already remodeled in response to chronically elevated pressures. 1, 3 The patient has moved beyond grade I (impaired relaxation with normal LA size and normal filling pressures). 3

Avoid aggressive diuresis in asymptomatic patients - Unlike symptomatic heart failure, asymptomatic diastolic dysfunction should not be treated with diuretics, as this may compromise cardiac output without proven benefit. 1

Monitor for atrial fibrillation - The moderately dilated left atrium increases risk for atrial arrhythmias, which would warrant anticoagulation consideration. 2

Addressing the Mild Valvular Disease

The mild valvular lesions require surveillance but not intervention:

• Mild aortic regurgitation with sclerosis - Follow clinically; repeat echocardiography every 2 years if stable and asymptomatic. 2
• Mild mitral regurgitation with annular calcification - This degree of MR does not require vasodilator therapy or surgical intervention. 2
• Mild tricuspid regurgitation - Provides useful information for estimating pulmonary pressures but does not require specific treatment. 2

Anticoagulation is not indicated unless atrial fibrillation develops or there is history of systemic embolism. 2