Diastolic Dysfunction Diagnosis and Grading

Core Diagnostic Parameters

The American Society of Echocardiography (ASE) and European Association of Cardiovascular Imaging (EACVI) recommend a structured, four-parameter approach to diagnose and grade left ventricular diastolic dysfunction using echocardiography, with specific cutoff values that differ based on whether ejection fraction is reduced or preserved 1, 2, 3
Mitral annular e' velocity should be measured, with septal e' < 7 cm/sec and lateral e' < 10 cm/sec considered abnormal 2, 3, 4
Average E/e' ratio should be calculated, with a ratio > 14 indicating elevated filling pressures 2, 3, 4
Left atrial (LA) maximum volume index should be measured, with a value > 34 mL/m² indicating chronically elevated filling pressures 2, 3, 4
Peak tricuspid regurgitant (TR) velocity should be measured, with a velocity > 2.8 m/sec indicating elevated pulmonary artery systolic pressure 1, 2, 5

The ASE and EACVI recommend a step-wise approach to grading diastolic dysfunction in patients with reduced ejection fraction, starting with evaluation of mitral inflow pattern 5
If E/A ≤ 0.8 and peak E ≤ 50 cm/sec, left atrial pressure (LAP) is considered normal, and diastolic dysfunction is graded as Grade I 5
If E/A ≤ 0.8 and peak E > 50 cm/sec, or if E/A is 0.8-2.0, proceed to Step 2, which involves applying a three-parameter rule using E/e' ratio, LA volume index, and TR velocity 5

The ASE and EACVI recommend a step-wise approach to grading diastolic dysfunction in patients with preserved ejection fraction, starting with assessment of structural abnormalities such as left ventricular hypertrophy and LA enlargement 5, 3
If diastolic parameters are inconclusive, consider measuring left ventricular global longitudinal strain (GLS), which can help diagnose myocardial dysfunction 2, 3

The ASE and EACVI recommend diastolic stress testing in patients with symptoms suggestive of heart failure with preserved ejection fraction, but with normal resting echocardiogram parameters 7, 8
A positive test is defined by the presence of all three of the following criteria during exercise: average E/e' > 14, peak TR velocity > 2.8 m/sec, and septal e' velocity < 7 cm/sec 1, 8

The ASE and EACVI recommend considering the prognostic implications of diastolic dysfunction, including the risk of heart failure and mortality, when grading diastolic dysfunction 1, 8
Restrictive filling pattern (E/A ≥ 2, DT < 160 msec) predicts worse outcomes independent of left ventricular ejection fraction (LVEF) 1
E/e' ratio correlates with functional class and prognosis better than LVEF alone 2