Should any exercise be avoided in a patient with a rising E/e′ of approximately 9 to prevent tachycardia and reduced left ventricular diastolic filling time?

Exercise is NOT Contraindicated with an E/e′ of 9

Exercise should be encouraged, not avoided, in a patient with an E/e′ of 9, as this value falls within the normal range and indicates preserved diastolic function at rest. The concern about tachycardia reducing filling time is theoretically valid but clinically misplaced at this stage of diastolic function.

Understanding the E/e′ Value of 9

• An E/e′ of 9 is definitively normal according to European and American guidelines, which define normal diastolic function as septal E/e′ <10 and average E/e′ <14 1.
• This value indicates that left ventricular filling pressures are not elevated at rest 1.
• The fact that E/e′ is "climbing" warrants monitoring but does not justify exercise restriction at this level 2.

Why Exercise is Beneficial, Not Harmful

Normal Hemodynamic Response Expected

• In healthy individuals and those with normal diastolic function (E/e′ <10), both mitral E velocity and annular e′ velocity increase proportionally during exercise, maintaining a stable E/e′ ratio 1.
• The European Society of Cardiology states that normal subjects increase stroke volume without significantly increasing filling pressures due to augmented myocardial relaxation and early diastolic suction 1, 3.
• With an E/e′ of 9, this patient should demonstrate normal diastolic reserve during exercise 1.

Exercise Training Improves Diastolic Function

• Endurance-type exercise training can improve indices of diastolic function, particularly in early stages of dysfunction 4.
• Dynamic endurance training causes parallel increases in left ventricular end-diastolic volume and wall thickness while maintaining normal wall stress, and induces relative bradycardia that actually prolongs diastolic filling time 4.
• A 2-year high-intensity exercise program reduced left ventricular stiffness in previously sedentary middle-aged individuals 4.

Addressing the Tachycardia Concern

The Tachycardia-Filling Time Relationship is Compensated

• While tachycardia does reduce diastolic filling time, normal hearts compensate through enhanced myocardial relaxation (increased e′ velocity), which maintains adequate filling despite shorter filling periods 1, 3.
• The European Society of Cardiology notes that "the faster the myocardial relaxation (e′ velocity), the higher the exercise capacity" 1, 3.
• Exercise training induces relative bradycardia at rest and submaximal workloads, which actually increases diastolic filling time over the long term 4.

When Tachycardia Becomes Problematic

• Tachycardia-related filling problems occur when E/e′ rises significantly during exercise (>13-15), indicating impaired diastolic reserve 1.
• The guidelines show that patients with diastolic dysfunction cannot augment e′ velocity appropriately, causing E/e′ to rise excessively with exercise 1.
• This patient's resting E/e′ of 9 suggests preserved diastolic reserve, making problematic tachycardia unlikely during moderate exercise 1.

Clinical Algorithm for Exercise Prescription

Step 1: Confirm Baseline Diastolic Function

• With E/e′ = 9, this patient has normal diastolic function at rest 1.
• Additional parameters to confirm: septal e′ velocity should be >7 cm/sec, lateral e′ >10 cm/sec, LA volume index <34 mL/m², and TR velocity <2.8 m/sec 1, 2.

Step 2: Consider Diastolic Stress Testing (Optional but Informative)

• Diastolic stress testing is indicated when resting echocardiography does not explain symptoms, particularly in patients with borderline parameters 1, 2.
• However, the American Society of Echocardiography states that patients with completely normal diastolic function at rest with preserved e′ velocity need not undergo stress testing as it is highly unlikely they will develop elevated filling pressures with exercise 1.
• If performed, a normal test shows E/e′ remaining <13-14 during exercise 1.

Step 3: Exercise Prescription

• Recommend moderate-intensity aerobic exercise 150 minutes per week or vigorous-intensity exercise 75 minutes per week 5.
• Dynamic endurance training (walking, cycling, swimming) is preferred over static resistance training for diastolic function optimization 4, 6.
• The American Society for Preventive Cardiology recommends exercise intensity at 40-80% of oxygen uptake reserve or heart rate reserve 5.

Step 4: Monitoring Strategy

• Serial echocardiographic assessment every 6-12 months to monitor for progression 2, 4.
• Watch for development of symptoms (dyspnea, exercise intolerance) that would prompt reassessment 1.
• If E/e′ rises above 14 or symptoms develop, consider diastolic stress testing to evaluate exercise-induced elevation in filling pressures 1, 2.

Common Pitfalls to Avoid

Pitfall 1: Overinterpreting "Climbing" E/e′

• An E/e′ "climbing" to 9 from a lower value (e.g., 6-7) represents normal age-related changes or measurement variability, not pathology requiring exercise restriction 1, 2.
• Only values >14 (average) or >15 (septal) indicate elevated filling pressures 1.

Pitfall 2: Misunderstanding Exercise Physiology

• The concern that "tachycardia reduces filling time" applies to patients with impaired diastolic reserve who cannot augment relaxation, not to those with normal E/e′ 1.
• Exercise-induced tachycardia in normal hearts is compensated by enhanced relaxation 1, 3.

Pitfall 3: Premature Exercise Restriction

• Restricting exercise in patients with normal diastolic function (E/e′ <10) is counterproductive, as exercise training may prevent progression to diastolic dysfunction 4.
• The American Heart Association recommends endurance exercise training to improve diastolic function indices 4.

When Exercise Should Be Modified or Restricted

Absolute Contraindications (Not Present Here)

• Hemodynamically significant aortic stenosis (exercise contraindicated until corrected) 4.
• Acute decompensated heart failure with elevated filling pressures at rest 1.
• Unstable coronary syndromes 5.

Relative Cautions Requiring Supervision

• If E/e′ rises above 14-15 or symptoms develop, exercise should be supervised with careful monitoring to avoid excessive dyspnea or pulmonary congestion 4.
• Patients with exercise-induced E/e′ >13 or systolic pulmonary artery pressure ≥50 mmHg have markers of adverse outcomes and require closer monitoring 1.

Bottom Line for This Patient

With an E/e′ of 9, this patient should engage in regular aerobic exercise without restriction. The theoretical concern about tachycardia reducing filling time does not apply to patients with normal diastolic function at rest. Exercise training will likely improve, not worsen, diastolic function and may prevent progression. Monitor E/e′ serially, and only consider exercise modification if it rises above 14 or symptoms develop 1, 4.