Diastolic Dysfunction and Systolic Impairment in Patients with Normal Ejection Fraction

Introduction to Diastolic Dysfunction

The European Society of Cardiology recommends referring patients with normal ejection fraction but reduced tissue Doppler velocity to cardiology, as this finding indicates underlying diastolic dysfunction or early systolic impairment that requires specialized evaluation and may predict adverse outcomes despite preserved ejection fraction 1

Reduced septal E' velocity (typically <8 cm/s indicates diastolic dysfunction) is a key parameter to evaluate, according to the European Heart Journal 1
Reduced lateral E' velocity (typically <10 cm/s is abnormal) is another important parameter to assess, as recommended by the European Heart Journal 1
Elevated E/E' ratio >15 suggests high left ventricular filling pressures and is the best noninvasive predictor of diastolic dysfunction, according to the European Heart Journal 1

Patients with heart failure with preserved ejection fraction (HFpEF) have normal ejection fraction by definition (≥50%) but suffer significant morbidity and mortality from diastolic dysfunction, as noted by the European Heart Journal and the American College of Cardiology 1, 2
Reduced tissue Doppler velocities correlate with decreased functional capacity measured by cardiopulmonary exercise testing, even when ejection fraction is normal, according to the European Heart Journal 1

The specialist will assess for conditions that present with this pattern, including heart failure with preserved ejection fraction (HFpEF), hypertrophic cardiomyopathy, infiltrative cardiomyopathies, and restrictive cardiomyopathy, as recommended by the European Heart Journal and the American Heart Association 1, 3
Heart failure with preserved ejection fraction (HFpEF) requires specific diagnostic criteria, including elevated natriuretic peptides and evidence of elevated filling pressures, according to the European Heart Journal 1

Symptoms of heart failure (dyspnea, orthopnea, edema) despite normal ejection fraction require urgent referral, as recommended by the European Heart Journal and the American College of Cardiology 1, 4
Left atrial enlargement (left atrial volume index ≥34 mL/m²) is a highly sensitive marker of chronic diastolic dysfunction, according to the European Heart Journal 1

Natriuretic peptides (BNP/NT-proBNP) are elevated in heart failure with preserved ejection fraction (HFpEF) and support diagnosis, as noted by the European Heart Journal 1
Global longitudinal strain (GLS) values <-16% indicate early systolic dysfunction even with normal ejection fraction, according to the European Heart Journal and the American Society of Echocardiography 3, 5
Cardiac MRI provides tissue characterization to detect fibrosis, infiltration, or hypertrophy, as recommended by the European Heart Journal and the American College of Cardiology 3, 4