A Guideline Protocol for the Echocardiographic assessment of Diastolic Dysfunction
Echocardiography plays a central role in the non-invasive evaluation of diastole and should be interpreted in the clinical context.
Multiple echocardiographic measurements have been proposed to assess diastolic function but no single parameter should be used in
isolation. This document gives recommendations for the image and analysis dataset required for the assessment of diastolic
dysfunction (DD) using established indices acquired as part of the minimum dataset. Due to the variable sensitivity and specificity
of the available parameters in different clinical settings, contradictory data can occur and in a proportion of patients a final diagnosis
may not be achieved. In these situations the conventional echo data should be supplemented with information from other forms of
assessment including haemodynamic measurement.
In this document, the parameters assessed are first set out systematically, with the key measurements highlighted in bold. For ease of
reference they are also listed below. A simplified flow chart follows to assist in diastolic dysfunction grading. Appendix 1
summarises normal values. Appendix 2 provides recommendations on assessing diastolic function in specific clinical situations.
Dr Thomas Mathew (lead author)
Dr Rick Steeds, Chair
Dr Richard Jones
Dr Prathap Kanagala
Dr Guy Lloyd
Dr Daniel Knight
Dr Kevin O'Gallagher
Dr David Oxborough
Dr Bushra Rana
Dr Liam Ring
Julie Sandoval
Gill Wharton
Dr Richard Wheeler
Abbreviations:
E Vmax Mitral valve early filling on PW Doppler (m/s)
A Vmax Mitral valve atrial filling (m/s)
A dur Duration of atrial filling wave on PW Doppler (ms)
E/A ratio Ratio of E Vmax/A Vmax
DT Deceleration time (ms)
PV s Pulmonary vein systolic wave peak velocity (m/s)
PV d Pulmonary vein diastolic wave peak velocity (m/s)
PV s/d Ratio of pulmonary vein peak systolic velocity/peak diastolic velocity
PV a dur Duration of atrial reversal from PW Doppler of pulmonary vein flow (ms)
LAi Left atrial volume indexed to body surface area (mls/m2)
e’ Velocity of early myocardial relaxation measured on tissue Doopler imaging (cm/s)
E/e’ Ratio of MV E Vmax/ tissue Doppler early myocardial relaxation velocity
Mitral Vp: Propagation velocity of early filling wave into the LV (cm/s)
NOTE: key parameters are highlighted in bold. The remaining parameters are useful adjuncts when the diagnosis of diastolic
dysfunction severity remains unclear
Published November 2013
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VIEW Modality Measurements Explanatory note for ARVC Image
A 4C PW E V max, Sample volume is placed at the level of
Doppler A V max, mitral leaflets tips (colour flow can be help-
E/A ratio ful for optimal alignment, particularly when
DT LV is dilated)
A dur
Optimise spectral gain/wall filters to ensure
clear crisp signal of onset and cessation of
LV inflow
Measurements are obtained over 3 cardiac
cycles at end expiration Normal
See appendix 1 for normal values
Grade 1
Grade 2
Grade 3
PW Change in Mitral E/A Decrease in 20cm/s in E wave velocity gen-
Doppler ratio from baseline erally indicates a good Valsalva technique
with
Valsalva Decrease in mitral E/A ratio of > _50% is
highly specific of raised LV filling pressure.
Useful when differentiating grade 2 from
normal.
Grade 2 before valsalva
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Above patient during valsalva
PW P Vs Superior angulation of the transducer in the
Doppler P Dd 4C view and colour flow is often required to
s / d r a t io locate the right upper pulmonary vein (seen
close to atrial septum).
a-dur Sample volume is placed >0.5cm into the
pulmonary vein
Wall filter settings should be lowered with a
faster sweep speed (50-100mm/s) to opti-
mise recording; aim to include clear visuali- Normal PV flow
sation of atrial reversal velocity waveform
Measurements are obtained over 3 cardiac
cycles at end expiration.
If there are 2 systolic peaks (S1 and S2),
peak S2 should be used to compute S/D
ratio
See appendix 1 for normal values
PV flow with S/D reversal
Calculate: a dur - A a dur-A dur of more than 30ms indicates
dur raised LV filling pressure
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A 4C Tissue e’ Velocities are recorded using PW TDI and
Doppler not colour coded TDI
imaging
(TDI) Sample volume is placed at or within 1cm of
the insertion site of mitral valve leaflets
Optimise the velocity scale and baseline to
demonstrate full signal. Gain settings
should be adjusted to display high ampli-
tude annular velocities.
Measurements are obtained over 3 cardiac
cycles at end expiration
e’ is unreliable in the presence of mitral
annular calcification, mitral prosthetic valves
and annuloplasty rings and severe mitral
valve disease
See appendix 1 for normal values
Ca l c u l a t e : e’ - average from 2 sites (lateral and septal)
E / e ’ ra t i o is used for the ratio.
A 4C Colour (Vp) Acquisition is performed in the 4c view with
M-Mode colour flow imaging (narrow colour sector)
Calculate : Mitral E/Vp across the mitral valve and an M mode line
ratio placed through the centre of the LV inflow
blood column (MV to LV apex).
Nyquist limit is adjusted to display the cen-
tral highest velocity jet as blue.
Flow propagation velocity (Vp) is measured
as the slope of the first aliasing velocity Normal Vp
measured from mitral valve plane to 4 cm
distally in to the LV cavity.
Mitral E/Vp ratio can be used to predict LA
pressure. E/Vp >2.5 indicates elevated LA
pressure (>15mmHg).
CW TR V max In the absence of lung or mitral valve dis-
Doppler ease, raised PA pressure may indicate DD.
A 4C 2D L A v o l um e Average volume measured at ventricular end
& systole (LA largest) using Modified Simpsons
A 2C Ca l c u l a t e : L A i or Area Length method and indexed to BSA
See minimum dataset and chamber quantifi-
cation guidelines
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E/A, DT, s/d, e’, LA volume
E/A < 1* E/A 1-2 E/A >2**
DT > 230 DT 130-230 DT <130
e’normal e’ reduced
Grade I Normal Grade II Grade III
*** *** *** ***
• e’ - reduced • LA – normal** • LA – ↑ • e’ – reduced
• LA – normal or ↑ • s/d > 1 • s/d <1 • LA – ↑
• s/d >1 • E/e’ <8# • E/e’ usually >
_13# • s/d <1
• E/e’ – usually <
_8 • E/e’ – > 13
Flow chart
*E/A < 1 without any additional evidence of diastolic dysfunction can be normal above 60 years of age.
**E/A >2 and/or increased LA size without structural heart disease can be seen in young subjects and athletes.
***Combined with one or more parameters from below. Confidence of categorisation increases with increasing
number of corroborative parameters.
# If E/e’ is between 9 and 12, additional measurements should be used (see text).
Figure 1: Practical approach to assessment and grading of Diastolic Dysfunction
Appendix 1
Measurement 16-20 years 21-40 years 41-60 years >60
Mitral E/A ratio 1.88 ± 0.45 (0.98-2.78) 1.53 ± 0.40 (0.73-2.33) 1.28 ± 0.25 (0.78-1.78) 0.96 ± 0.18 (0.6-1.32)
Mitral DT (ms) 142 ± 19 (104-180) 166 ± 14 (138-194) 181 ± 19 (143-219) 200 ± 29 (142-258)
PV S/D ratio 0.82 ± 0.18 (0.46-1.18) 0.98 ± 0.32 (0.34-1.62) 1.21 ± 0.2 (0.81-1.61) 1.39 ± 0.47 (0.45-2.33)
Septal e’ (cm/s) 14.9 ± 2.4 (10.1-19.7) 15.5 ± 2.7 (10.1-20.9) 12.2 ± 2.3 (7.6-16.8) 10.4 ± 2.1 (6.2-14.6)
Lateral e’(cm/s) 20.6 ± 3.8 (13-28.2) 19.8 ± 2.9 (14-25.6) 16.1 ± 2.3 (11.5-20.7) 12.9 ± 3.5 (5.9-19.9)
Table 1. Normal values for age related Doppler derived diastolic measurements. Data are expressed as Mean ± SD (95% confi-
dence interval) except those marked with asterisk. Adapted from reference 1.
Appendix 2
In certain clinical situations, conventional echo indices cannot be readily applied to assess diastolic dysfunction. The following
section provides recommendations on assessing diastolic function in this group of patients. In these patients, grading of DD is not
always possible and the aim is to estimate the filling pressures as a marker of diastolic dysfunction.
a. Left ventricular hypertrophy: In patients with heart failure symptoms and normal EF, evidence of concentric remodelling or raised
LV mass index is itself indicative of diastolic dysfunction. In this group of patients, assessment of other markers of diastolic
dysfunction does not provide additional diagnostic information
b. Sinus tachycardia: E A fusion occurs rendering E/A ratio and deceleration time unreliable in assessing DD. E/e’ ratio using fused
peak mitral inflow velocity and peak fused mitral annular velocity can still be used to predict LV filling pressures in this situation.
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c. Atrial Fibrillation: Loss of atrial contraction, variable cycle length and the frequent occurrence of atrial dilatation limit the
usefulness of conventional indices in the assessment of DD. DT and E/e’ ratio averaged over 5-10 cardiac cycles (recorded from
cycle lengths equivalent to a heart rate between 60-80 beats/minute) can be used to assess LV filling pressures in this group.
d. Constrictive pericarditis: Constrictive pericarditis can present with heart failure symptoms and restrictive filling pattern (Grade
III) in the absence of diastolic dysfunction. Normal or increased e’ velocity can differentiate this condition from DD.
e. Mitral valve disease: Mitral E Vmax and PVs are affected by significant primary MR. a dur- A dur is the strongest predictor of
LV filling pressure in this situation.
f. Systolic dysfunction: Grading of DD and estimation of filling pressures provide additional prognostic information in patients with
established systolic dysfunction. Mitral inflow pattern (E/A ratio and DT) alone can be used to estimate filling pressure in this
population and no further evaluation is necessary except in borderline cases. Accordingly E/A ratio < 1 in this population often
indicates normal filling pressures and E/A ratio of 1-2 or > 2 strongly suggest raised pressures.
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