In an older patient with possible diastolic dysfunction, hypertension and a history of heart failure, can the E/e′ ratio be inferred or calculated from other echocardiographic parameters when the early diastolic mitral annular velocity (e′) was not measured?

Can E/e' Be Calculated from Other Echo Parameters?

No, E/e' cannot be reliably calculated or inferred from other standard echocardiographic parameters when e' (early diastolic mitral annular velocity) is not directly measured—you must obtain tissue Doppler imaging of the mitral annulus to calculate this ratio. 1, 2

Why E/e' Requires Direct Measurement

The E/e' ratio requires two distinct measurements that reflect different physiological processes:

• E velocity (early transmitral flow) is measured by conventional pulsed-wave Doppler and reflects the pressure gradient between left atrium and left ventricle, influenced by LV relaxation, restoring forces, and left atrial pressure 1

• e' velocity (early diastolic mitral annular velocity) is measured by tissue Doppler imaging and primarily reflects LV myocardial relaxation with minimal loading condition influence 1, 3

These are fundamentally different measurements that cannot substitute for each other. While you have the E velocity from standard mitral inflow Doppler, the e' velocity requires specific tissue Doppler interrogation of the mitral annulus that is not part of routine echo protocols. 4, 2

What You Can Assess Without E/e'

In your patient with possible diastolic dysfunction, hypertension, and heart failure history, you can still evaluate diastolic function using alternative parameters:

Mitral Inflow Pattern Analysis

• E/A ratio ≥2 indicates elevated left atrial pressure and Grade III (restrictive) diastolic dysfunction 1
• E/A ratio ≤0.8 with peak E velocity ≤50 cm/sec suggests normal/low mean left atrial pressure (Grade I diastolic dysfunction) 1
• Values between these extremes require additional parameters including E/e' for accurate classification 1

Deceleration Time

• DT <160 msec when accompanied by E/A ≥2 indicates Grade III diastolic dysfunction 5
• Normal DT for patients >60 years is 142-258 msec 4, 5

Other Supporting Parameters

• Left atrial volume index >34 mL/m² suggests chronically elevated filling pressures 1
• Tricuspid regurgitation peak velocity >2.8 m/sec indicates elevated right-sided pressures that often accompany elevated LV filling pressures 1

The Recommended Solution

Request a complementary focused echocardiogram with tissue Doppler imaging specifically targeting the mitral annulus to obtain septal and lateral e' velocities. 1 This is essential for:

• Calculating E/e' ratio to estimate LV filling pressures (normal <8, elevated >14) 4, 1
• Distinguishing pseudonormalization from truly normal diastolic function in patients with intermediate E/A ratios 6
• Providing prognostic information, as E/e' ≥15 independently predicts adverse outcomes in hypertensive patients 4

Measurement Technique When Obtained

• Measure e' at both septal and lateral mitral annulus positions 4, 2
• Use the average of septal and lateral values for optimal assessment, particularly important in patients with regional LV dysfunction 4, 1
• Normal age-adjusted values for patients >60 years: septal e' ≥6.2 cm/s, lateral e' ≥5.9 cm/s 4, 2

Critical Caveats

E/e' has important limitations even when properly measured:

• Heavy mitral annular calcification, mitral valve disease, pericardial disease, and regional wall motion abnormalities reduce accuracy 1
• The correlation between E/e' and invasively measured filling pressures is only modest (r=0.56) 1
• Values between 8-15 are indeterminate and require integration with other parameters 1

In your hypertensive patient with heart failure history, E/e' measurement is specifically recommended by guidelines as part of detecting cardiac target organ damage and assessing filling pressures. 4 The investment in obtaining proper tissue Doppler imaging is justified given the prognostic and therapeutic implications.