ASE/EACVI GUIDELINES AND STANDARDS

Recommendations for the Evaluation of Left
Ventricular Diastolic Function by Echocardiography:
An Update from the American Society of
Echocardiography and the European Associationof Cardiovascular Imaging
Sherif F. Nagueh, Chair, MD, FASE,1 Otto A. Smiseth, Co-Chair, MD, PhD,2 Christopher P. Appleton, MD,1
Benjamin F. Byrd, III, MD, FASE,1 Hisham Dokainish, MD, FASE,1 Thor Edvardsen, MD, PhD,2Frank A. Flachskampf, MD, PhD, FESC,2 Thierry C. Gillebert, MD, PhD, FESC,2 Allan L. Klein, MD, FASE,1
Patrizio Lancellotti, MD, PhD, FESC,2 Paolo Marino, MD, FESC,2 Jae K. Oh, MD,1
Bogdan Alexandru Popescu, MD, PhD, FESC, FASE,2 and Alan D. Waggoner, MHS, RDCS1, Houston, Texas;
Oslo, Norway; Phoenix, Arizona; Nashville, Tennessee; Hamilton, Ontario, Canada; Uppsala, Sweden; Ghent andLie ge, Belgium; Cleveland, Ohio; Novara, Italy; Rochester, Minnesota; Bucharest, Romania; and St. Louis, Missouri(J Am Soc Echocardiogr 2016;29:277-314.)
Keywords: Diastole, Echocardiography, Doppler, Heart failure

TABLE OF CONTENTS

I. General Principles for Echocardiographic Assessment of LV Diastolic
Function 278
II. Diagnosis of Diastolic Dysfunction in the Presence of Normal
LVEF 279
III. Echocardiographic Assessment of LV Filling Pressures and Diastolic
Dysfunction Grade 281
IV. Conclusions on Diastolic Function in the Clinical Report 288
V. Estimation of LV Filling Pressures in Specific Cardiovascular
Diseases 288
A. Hypertrophic Cardiomyopathy 289
B. Restrictive Cardiomyopathy
289
C. Valvular Heart Disease 290
D. Heart Transplantation
292
E. Atrial Fibrillation
295

F. Atrioventricular Block and Pacing
296
VI. Diastolic Stress Test
298
A. Indications
299
B. Performance 299
C. Interpretation 301
D. Detection of Early Myocardial Disease and Prognosis 301
VII. Novel Indices of LV Diastolic Function 301
VIII. Diastolic Doppler and 2D Imaging Variables for Prognosis in Patientswith HFrEF 303
IX. Prediction of Outcomes in Patients with HFpEF 303
Reviewers 306
Notice and Disclaimer 307

From the Methodist DeBakey Heart and Vascular Center, Houston, Texas (S.F.N.);
the University of Oslo, Oslo, Norway (O.A.S., T.E.); Mayo Clinic Arizona, Phoenix,
Arizona (C.P.A.); Vanderbilt University School of Medicine, Nashville, Tennessee(B.F.B.); McMaster University, Hamilton, Ontario, Canada (H.D.); Uppsala
University, the Institute of Medical Sciences, Uppsala, Sweden (F.A.F.); Ghent
University and University Hospital, Ghent, Belgium (T.C.G.); Cleveland Clinic,
ge Hospital, Liege, Belgium (P.L.);
Cleveland, Ohio (A.L.K.); the University of Lie
Universita Piemonte Orientale, Novara, Italy (P.M.); Mayo Clinic, Rochester,
Minnesota (J.K.O.); the University of Medicine and Pharmacy ‘‘Carol Davila,’’Institute of Cardiovascular Diseases, Bucharest, Romania (B.A.P.); andWashington University School of Medicine, St Louis, Missouri (A.D.W.).

Popescu, MD, PhD, has received research support from GE Healthcare and Hitachi Aloka.

The following authors reported no actual or potential conflicts of interest in relation
to the document: Sherif F. Nagueh, MD, Otto Smiseth, MD, PhD, Christopher P.
Appleton, MD, Benjamin F. Byrd III, MD, Hisham Dokainish, MD, Thor Edvardsen,
MD, PhD, Frank A. Flachskampf, MD, PhD, Thierry C. Gillebert, MD, PhD, Allan
Klein, MD, Patrizio Lancellotti, MD, PhD, Paolo Marino, MD, and Alan D. Waggoner, MHS, RDCS. The following authors reported relationships with one ormore commercial interests: Jae K. Oh, MD, has served as a consultant for
Medtronic and received a research grant from Toshiba. Bogdan Alexandru

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Boulevard, Suite 310, Morrisville, NC 27560 (E-mail: ase@asecho.org).
1
2

Writing Committee of the American Society of Echocardiography.
Writing Committee of the European Association of Cardiovascular Imaging.

0894-7317/$36.00
Copyright 2016 by the American Society of Echocardiography.
http://dx.doi.org/10.1016/j.echo.2016.01.011

277

278 Nagueh et al

Echocardiographic assessment ofleft ventricular (LV) diastolic
2D = Two-dimensional
function is an integral part of
the routine evaluation of patients
AR = Aortic regurgitation
presenting with symptoms of
ASE = American Society ofdyspnea or heart failure. The
Echocardiography
2009 American Society of
Echocardiography (ASE) andAV = Atrioventricular
European Association of EchoCW = Continuous-wave
cardiography (now European
Association of Cardiovascular
DT = Deceleration time
Imaging [EACVI]) guidelines for
EACVI = European
diastolic function assessment
Association of Cardiovascularwere comprehensive, including
Imaging
several two-dimensional (2D)
EF = Ejection fraction
and Doppler parameters tograde diastolic dysfunction and
GLS = Global longitudinal
to estimate LV filling pressures.1
strainNotwithstanding, the inclusion
HCM = Hypertrophic
of many parameters in the guidecardiomyopathylines was perceived to render
HFpEF = Heart failure withdiastolic function assessment
preserved ejection fraction
too complex, because several
readers have interpreted the
HFrEF = Heart failure withguidelines as mandating all the
reduced ejection fraction
listed parameters in the docuIVRT = Isovolumic relaxation
ment to fall within specified
timevalues before assigning a specificgrade. The primary goal of thisLA = Left atrial
update is to simplify the
LAP = Left atrial pressure
approach and thus increase the
LV = Left ventricularutility of the guidelines in dailyclinical practice.
LVEDP = Left ventricular
LV diastolic dysfunction is
end-diastolic pressure
usually the result of impaired
LVEF = Left ventricular
LV relaxation with or withoutejection fraction
reduced restoring forces (andearly diastolic suction), and
MAC = Mitral annularincreased LV chamber stiffness,
calcification
which increase cardiac filling
MR = Mitral regurgitationpressures. Thus, when performPASP = Pulmonary arterying an echocardiographic study
systolic pressurein patients with potential diastolic dysfunction, one should
PCWP = Pulmonary capillary
search for signs of impaired LV
wedge pressure
relaxation, reduced restoring
RV = Right ventricularforces and increased diastolic
stiffness. More important, LV
STE = Speckle-tracking
filling pressure should be estiechocardiography
mated because elevated LV diaTR = Tricuspid regurgitation
stolic pressure in the absence of
Vp = Flow propagation
increased LV end-diastolic volvelocity
ume is strong evidence in favorof well-developed diastolic
dysfunction. In the majority of clinical studies, LV filling pressuresand diastolic function grade can be determined reliably by a few
simple echocardiographic parameters with a high feasibility. In addition, technical developments have emerged that provide new
indices that appear promising for studying LV diastolic function.
This update places more emphasis on applying the most useful,Abbreviations

Journal of the American Society of Echocardiography
April 2016

reproducible, and feasible 2D and Doppler measurements fromthe 2009 guidelines.
Before applying the guidelines, it is essential to consider what the term
LV filling pressures refers to. The term LV filling pressures can refer to mean
pulmonary capillary wedge pressure (PCWP) (which is an indirect estimate of LV diastolic pressures), mean left atrial (LA) pressure (LAP), LV
pre-A pressure, mean LV diastolic pressure, and LVend-diastolic pressure(LVEDP). The different LV and LA diastolic pressures mentioned above(Figure 1) have different correlates with Doppler signals. For example,
in the early stages of diastolic dysfunction, LVEDP is the only abnormallyelevated pressure because of a large atrial pressure wave, while mean
PCWP and LAP remain normal. With tachycardia and/or increased LV
afterload, mean PCWP and LAP increase which provides the basis forthe diastolic stress test. Thus, it is important that one is clear on which pressure is being estimated as there are different Doppler variables that correlate with an increase in LVEDP only versus those that reflect an increase inboth LAP and LVEDP. Although the current recommendations arefocused on echocardiographic techniques, it should be noted that both
nuclear scans and cardiac magnetic resonance can be used to evaluate
LV filling rates and volumes. Notably, measurements derived by bothtechniques are affected by LV relaxation and LV filling pressures andare quite similar to measurements and derivatives obtained from mitral
inflow velocities.
Tables 1 and 2 summarize the technical aspects, hemodynamic
determinants, and clinical applications including limitations of each of
the Doppler and 2D parameters.2-50 Doppler signals that occur at enddiastole correlate best with LVEDP. These include mitral peak A velocity
at tips level, A-wave duration at the annulus, A velocity deceleration time(DT), pulmonary vein peak Ar velocity, Ar velocity duration, Ar-A duration, and tissue Doppler–derived mitral annular a0 velocity. Mitral peak Ewave velocity, E/A ratio, E velocity DT, E/e0 ratio, pulmonary veinsystolic-to-diastolic velocity ratio, and peak velocity of tricuspid regurgitation (TR) by continuous-wave (CW) Doppler relate best with earlier
occurring LV diastolic pressures (mean PCWP, pre-A pressure, andmean LV diastolic pressure).

I. GENERAL PRINCIPLES FOR ECHOCARDIOGRAPHICASSESSMENT OF LV DIASTOLIC FUNCTION
The application of the guidelines starts with taking note of the clinical data, heart rate, blood pressure, 2D and Doppler findings withrespect to LV volumes/wall thickness, ejection fraction (EF), LA
volume, presence and severity of mitral valve disease as well as
the underlying rhythm. The guidelines are not necessarily applicable to children or in the perioperative setting. This is an important first step because there may be recommendations that are
specific to the underlying pathology. Second, the quality of the
Doppler signal as well as the limitations for each parameter should
be carefully examined. If a Doppler signal is suboptimal, that signal
should not be used in formulating conclusions about LV diastolic
function (Figures 2 and 3). Third, the presence of a single
measurement that falls within the normal range for a given age
group does not necessarily indicate normal diastolic function (seebelow). Given the several hemodynamic factors that affect eachsignal, some measurements may fall in the normal range despite
the presence of diastolic dysfunction, and none of the indicesshould be used in isolation. Therefore, consistency between two
or more of the indices should be relied upon in an individual
patient. The echocardiographic indices of diastolic function

Journal of the American Society of Echocardiography
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Nagueh et al 279

Figure 1 (Left) LV diastolic pressures recording. Arrows point to LV minimal pressure (min), LV rapid filling wave (RFW),
LV pre-A pressure (pre-A), A wave rise with atrial contraction and end-diastolic pressure (EDP). (Middle) LAP recording
showing ‘‘V’’ and ‘‘A’’ waves marked along with Y and X descent (Right) Simultaneous LV and LAP recording showing
early and late transmitral pressure gradients. Notice that LA ‘‘A wave’’ pressure precedes the late diastolic rise (LV
A wave) in LV pressure.

should always be interpreted in a wider context that includes
clinical status and the other 2D and other Doppler parameters.
Although often overlooked in reporting, the underlying
pathology shown by 2D and color Doppler is critical to reaching
the correct conclusions about LV diastolic function. For example,
the algorithm for estimation of LV filling pressures is less likely to
be helpful in a patient with normal vital signs and normal 2D
and Doppler findings.
With respect to the grading of LV diastolic dysfunction, it is therecommendation of the writing group to determine the grade ofdiastolic function based on the presence or absence of elevated
LV filling pressures as a first step. While useful in some cases,
the lower feasibility and reproducibility of flow propagation velocity (Vp) and time intervals (TE-e0 ) led the writing group to placeless emphasis on their routine acquisition and analysis. The
writing group strived to recommend algorithms that are applicable to most patients with cardiac disease. Notwithstanding thiseffort, the algorithms are not 100% accurate. For the most successful application of the guidelines, it is incumbent on the echocardiographer to have a solid understanding of the physiologic
rationale behind each variable, the situations that make any given
variable less reliable, and the technical aspects and acquisition andanalysis of Doppler and 2D signals.
The following sections are applicable to the general population ofpatients seen in an echocardiography laboratory but not in the presence of specific diseases or rhythm disorders, which are discussed
separately later on in the document.

II. DIAGNOSIS OF DIASTOLIC DYSFUNCTION IN THE
PRESENCE OF NORMAL LVEF
Differentiation between normal and abnormal diastolic function
is complicated by overlap between Doppler indices values inhealthy individuals and those with diastolic dysfunction.
Furthermore, normal aging is associated with a number ofchanges in the heart and vascular system, especially slowing of
LV relaxation which may lead to diastolic dysfunction.

Therefore, filling patterns in the elderly resemble those observedin mild diastolic dysfunction in younger patients (40–60 years),
and age should be taken into account when evaluating diastolic
function variables.51-65
The mechanisms of diastolic dysfunction in healthy sedentary
elderly appear to be due in part to increased LV stiffness
compared with younger individuals.63 Presumably there is also
slowing of myocardial relaxation in the elderly, which can accountfor the decrease in mitral E/A ratio and in e0 velocity (Figure 4),
but the data on aging and relaxation are not entirely consistentacross the studies.64 Furthermore, apparently healthy older individuals may have undetected coronary artery disease or othersubclinical disorders that could lead to the wide normal ranges.
Some indices, however, are less age dependent, and this includes
E/e0 ratio, which is very rarely >14 in normal individuals,52
changes in mitral inflow velocities with Valsalva maneuver, andthe difference in duration between pulmonary vein Ar velocity
and mitral A velocity. The Valsalva maneuver can help distinguishnormal LV filling from pseudonormal filling (and whether restrictive LV filling is reversible or not) because a decrease in E/A ratio
of $50%, not caused by E and A velocities fusion, is highly specific for increased LV filling pressures and supports the presenceof diastolic dysfunction (Figures 5 and 6). The procedure should
be standardized by continuously recording mitral inflow using
pulsed-wave Doppler for 10 sec during the straining phase of
the maneuver.1,14 Likewise, an increase in pulmonary vein Ar
velocity duration versus mitral A duration (Ar-A) is consistent
with increased LVEDP and diastolic dysfunction. Pulmonary
artery systolic pressure (PASP), provided pulmonary vasculardisease is excluded, can identify patients with increased LV
filling pressures as resting values for estimated PASP are
relatively age independent (Table 3). In many patients, LV and
LA structural changes may help differentiate between normal
and abnormal diastolic function.1 Similar to LA enlargement in
the absence of chronic atrial arrhythmia, which is often a marker
of long-term or chronic elevation of LAP, pathologic LV hypertrophy is usually associated with increased LV stiffness and diastolic
dysfunction.1 Furthermore, in patients with heart failure with preserved EF (HFpEF), LV global longitudinal function is often

280 Nagueh et al

Journal of the American Society of Echocardiography
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Table 1 Two-dimensional and Doppler methods for assessment of LV diastolic function
Variable

Acquisition

AnalysisPeak E-wave
velocity(cm/sec)

1. Apical four-chamber with color flow imaging for optimal
Peak modal velocity in early diastole (after ECG T wave) at thealignment of PW Doppler with blood flow.
leading edge of spectral waveform
2. PW Doppler sample volume (1–3 mm axial size) between
mitral leaflet tips.
3. Use low wall filter setting (100–200 MHz) and low signal gain.
4. Optimal spectral waveforms should not display spikes
or feathering.

Peak A-wave
velocity(cm/sec)

1. Apical four-chamber with color flow imaging for optimal
Peak modal velocity in late diastole (after ECG P wave) at thealignment of PW Doppler with blood flow
leading edge of spectral waveform
2. PW Doppler sample volume (1–3 mm axial size) between
mitral leaflet tips.
3. Use low wall filter setting (100–200 MHz) and low signal gain.
4. Optimal spectral waveforms should not display spikes
or feathering.

MV A duration(msec)

1. Apical four-chamber with color flow imaging for optimal
Time interval from A-wave onset to end of A wave at zeroalignment of PW Doppler with blood flow.
baseline. If E and A are fused (E velocity > 20 cm/sec when A
2. PW Doppler sample volume (1–3 mm axial size) at level ofvelocity starts), A-wave duration will often be longer because
mitral annulus (limited data on how duration comparesof increased atrial filling stroke volume.
between annulus and leaflet tips)
3. Use low wall filter setting (100–200 MHz) and low signal gain.
4. Optimal spectral waveforms should not display spikes
or feathering.

MV E/A ratio

See above for proper technique of acquisition of E andA velocities.

MV DT (msec)

Apical four-chamber: pulsed Doppler sample volume between Time interval from peak E-wave along the slope of LV filling
mitral leaflet tips
extrapolated to the zero-velocity baseline.

MV E velocity divided by A-wave velocity

1. Apical four-chamber view: PW Doppler sample volume
Pulsed-wave(usually 5–10 mm axial size) at lateral and septal basal
TDI e0 velocity(cm/sec)
regions so average e0 velocity can be computed.
2. Use ultrasound system presets for wall filter and lowest
signal gain.
3. Optimal spectral waveforms should be sharp and notdisplay signal spikes, feathering or ghosting.

Peak modal velocity in early diastole at the leading edge ofspectral waveform

Mitral E/e0

MV E velocity divided by mitral annular e0 velocity

See above for acquisition of E and e0 velocities

LA maximum
1. Apical four- and two-chamber: acquire freeze frames 1–2 Method of disks or area-length method and correct for BSA. Do
not include LA appendage or pulmonary veins in LA tracings
volume index
frames before MV opening.
from apical four- and apical two-chamber views.
(mL/BSA)
2. LA volume should be measured in dedicated views in which
LA length and transverse diameters are maximized.
PV S wave(cm/sec)

1. Apical four-chamber with color flow imaging to help position Peak modal velocity in early systole at the leading edge ofpulsed Doppler sample volume (1–3 mm axial size).
spectral waveform
2. Sample volume placed at 1–2 cm depth into right (or left)
upper PV.
3. Use low wall filter setting (100–200 MHz) and low signal gain.
4. Optimized spectral waveforms should not display signal
spikes or feathering.

PV D wave(cm/sec)

Same as for PV S wave.

PV AR duration(msec)

Apical four-chamber: sample volume placed at 1–2 cm depth Time interval from AR-wave onset to end of AR at zero baseline
into right (or left) upper PV with attention to presence of
LA wall motion artifacts

PV S/D ratio

See above for acquisition of pulmonary vein S and D velocities. PV S wave divided by D-wave velocity or PV S wave timevelocity integral/PV D wave time-velocity integral.

CW Doppler:TR systolic
jet velocity(m/sec)1. Parasternal and apical four-chamber view with color
flow imaging to obtain highest Doppler velocityaligned with CW.
2. Adjust gain and contrast to display complete spectralenvelope without signal spikes or feathering

Peak modal velocity in early diastole after MV opening at
leading edge of spectral waveform

Peak modal velocity during systole at leading edge of spectral
waveform(Continued )Nagueh et al 281

Journal of the American Society of Echocardiography
Volume 29 Number 4

Table 1 (Continued )Variable

Valsalva
maneuver

Acquisition

Analysis

Recording obtained continuously through peak inspiration and Change in MV E velocity and E/A ratio during peak strain andas patient performs forced expiration for 10 sec withfollowing releasemouth and nose closed.

Secondary measures
Color
Apical four-chamber with color flow imaging for M-mode
M-modecursor position, shift color baseline in direction of mitralVp (cm/sec)
valve inflow to lower velocity scale for red/yellow inflow
velocity profile

Slope of inflow from MV plane into LV chamber during early
diastole at 4-cm distance

IVRT

Apical long-axis or five-chamber view, using CW Doppler and Time between aortic valve closure and MV opening. For IVRT,
placing sample volume in LV outflow tract tosweep speed should be 100 mm/sec.
simultaneously display end of aortic ejection and onset of
mitral inflow.

TE-e0

Apical four-chamber view with proper alignment to acquire
mitral inflow at mitral valve tips and using tissue Doppler
to acquire septal and lateral mitral annular velocities.

Time interval between peak of R wave in QRS complex andonset of mitral E velocity is subtracted from time interval
between QRS complex and onset of e0 velocity. RR intervals
should be matched and gain and filter settings should be
optimized to avoid high gain and filter settings. For timeintervals, sweep speed should be 100 mm/sec.

A, atrial filling; AR, Atrial reversal; BSA, body surface area; CW, continuous wave; D, diastole; e0 , early diastolic; E, early filling; ECG, electrocardiographic; IVRT, isovolumic relaxation time; LA, left atrium; MV, mitral valve; PV, pulmonary vein; PW, pulsed-wave; S, systole; TDI, tissue Doppler
imaging; TR, tricuspid regurgitation.
All Doppler and M-mode recordings are preferably acquired at a sweep speed of 100 mm/sec.

impaired and thus may be used to differentiate between normal
and abnormal myocardial function.66 Although not an index of
LV diastolic function, abnormal LV longitudinal systolic function
can be detected by measurements of the mitral annular plane systolic excursion using M-mode, tissue Doppler–derived mitralannulus systolic velocity, and LV global longitudinal strain (GLS)by speckle-tracking. This approach has not been widely tested,
but in patients with normal EFs and inconclusive data after evaluating diastolic filling, the finding of impaired GLS and reduced
s0 velocity can be used as an indication of myocardial dysfunction.
The reduced longitudinal strain in patients with HFpEF is consistent with several studies that have demonstrated reduced systolicmitral annular velocity in this patient population. It is also
consistent with the fact that LV systolic and diastolic functions
are tightly coupled.
In summary, the following four variables should be evaluatedwhen determining whether LV diastolic function is normal(Figure 7) or abnormal. The presence of several abnormal findings
as well as cutoff values with high specificity for myocardial diseaseis recommended to decrease false positive diagnoses of diastolic
dysfunction. The four recommended variables and their abnormal
cutoff values are annular e0 velocity (septal e0 < 7 cm/sec, laterale0 < 10 cm/sec), average E/e0 ratio > 14, LA maximum volume index > 34 mL/m2, and peak TR velocity > 2.8 m/sec. On the basisof the writing group’s collective expert opinion, average E/e0 ratio isrecommended for simplification. Although E/e0 ratio may be obtained at septal or lateral annulus, and different values exist becauseof the normally higher lateral annular velocities, an average E/e0 ratio > 14 is used throughout this document and is consistent withrecent studies in normal subjects.52 It is recognized that at times
only the lateral e0 or septal e0 velocity is available and clinically valid
and in these circumstances a lateral E/e0 ratio > 13 or a septal E/e0 >15 is considered abnormal. The latter sentence applies to laboratories that acquire only septal or lateral velocities. The above are
general guidelines for annular velocities and ratios. Age appropriate

cutoff values, when available, should be considered when evaluatingolder individuals. LA maximum volume index is recommended andnot LA anteroposterior diameter by M-mode, as LA enlargement
can occur in the medial-lateral and superior-inferior directions
only, resulting in an increased LA volume while the chamber anteroposterior diameter is still within the normal range.
LV diastolic function is normal if more than half of the available
variables do not meet the cutoff values for identifying abnormal
function. LV diastolic dysfunction is present if more than half of
the available parameters meet these cutoff values. The study isinconclusive if half of the parameters do not meet the cutoff values(Figure 8A). For example, a 60-year-old patient with a septal e0 velocity of 6 cm/sec, septal E/e0 ratio of 10, LA maximum volume
index of 30 mL/m2, but no recorded TR signal has normal diastolic function.

Key Points
1. The four recommended variables for identifying diastolic dysfunction and theirabnormal cutoff values are annular e0 velocity: septal e0 < 7 cm/sec, lateral e0 <10 cm/sec, average E/e0 ratio > 14, LA volume index > 34 mL/m2, and peak TR velocity> 2.8 m/sec.
2. LV diastolic function is normal if more than half of the available variables do not meetthe cutoff values for identifying abnormal function. LV diastolic dysfunction is present if more than half of the available parameters meet these cutoff values. The study
is inconclusive if half of the parameters do not meet the cutoff values.

III. ECHOCARDIOGRAPHIC ASSESSMENT OF LV FILLINGPRESSURES AND DIASTOLIC DYSFUNCTION GRADE
The key variables recommended for assessment of LV diastolic
function grade include mitral flow velocities, mitral annular e0 velocity, E/e0 ratio, peak velocity of TR jet, and LA maximum volume
index (Figure 8B). Supplementary methods are pulmonary vein velocities and as a means to identify mild reduction in systolic

Variable

Utility and physiologic background

Advantages

Limitations

E-wave velocity reflects the LA-LV pressure gradient 1. Feasible and reproducible.
during early diastole and is affected by alterations in 2. In patients with dilated cardiomyopathy andthe rate of LV relaxation and LAP.
reduced LVEF, mitral velocities correlatebetter with LV filling pressures, functionalclass, and prognosis than LVEF.

1. In patients with coronary artery disease andpatients with HCM in whom LVEF is >50%,
mitral velocities correlate poorly with LV fillingpressures
2. More challenging to apply in patients witharrhythmias.
3. Directly affected by alterations in LV volumes
and elastic recoil.
4. Age dependent (decreasing with age).

Mitral A velocity

A-wave velocity reflects the LA-LV pressure gradient Feasible and reproducible.
during late diastole, which is affected by LV
compliance and LA contractile function.

1. Sinus tachycardia, first-degree AV block andpaced rhythm can result in fusion of the E and A
waves. If mitral flow velocity at the start of atrial
contraction is >20 cm/sec, A velocity may
be increased.
2. Not applicable in AF/atrial flutter patients.
3. Age dependent (increases with aging).

Mitral E/A ratio

Mitral inflow E/A ratio and DT are used to identify the 1. Feasible and reproducible.
2. Provides diagnostic and prognostic information.
filling patterns: normal, impaired relaxation, PN,
and restrictive filling.
3. In patients with dilated cardiomyopathy, filling
patterns correlate better with filling pressures,functional class, and prognosis than LVEF.
4. A restrictive filling pattern in combination with LA
dilation in patients with normal EFs is
associated with a poor prognosis similar to a
restrictive pattern in dilated cardiomyopathy.

1. The U-shaped relation with LV diastolic function
makes it difficult to differentiate normal fromPN filling, particularly with normal LVEF,
without additional variables.
2. If mitral flow velocity at the start of atrial
contraction is >20 cm/sec, E/A ratio will be
reduced due to fusion.
3. Not applicable in AF/atrial flutter patients.
4. Age dependent (decreases with aging).

Mitral E-velocity
DT

DT is influenced by LV relaxation, LV diastolicpressures following mitral valve opening, and LV
stiffness.

1. DT does not relate to LVEDP in normal LVEF
2. Should not be measured with E and A fusion due
to potential inaccuracy.
3. Age dependent (increases with aging).
4. Not applied in atrial flutter.

Changes in
mitral inflow
with Valsalva
maneuverHelps distinguishing normal from PN filling patterns. A When performed adequately under standardized
decrease of E/A ratio of $50% or an increase in Aconditions (keeping 40 mm Hg intrathoracic
wave velocity during the maneuver, not caused by Epressure constant for 10 sec) accuracy inand A fusion, are highly specific for increased LV
diagnosing increased LV filling pressures is good.
filling pressures.

Mitral ‘‘L’’
velocity

When present in patients with known cardiac disease Rarely seen in normal LV diastolic function when theMarkedly delayed LV relaxation in the setting ofelevated LV filling pressures allows for ongoing LV(e.g., LVH, HCM), it is specific for elevated LV filling
subject has bradycardia but it is then usuallyfilling in mid diastole and thus L velocity. Patientspressures. However, its sensitivity is overall low.
<20 cm/sec.
usually have bradycardia.

IVRT

IVRT is #70 msec in normal subjects and is prolonged 1. Overall feasible and reproducible.
in patients with impaired LV relaxation but normal 2. IVRT can be combined with other mitral inflow
LV filling pressures. When LAP increases, IVRT
parameters as E/A ratio to estimate LV fillingpressures in patients with HFrEF.

1. Feasible and reproducible.
2. A short DT in patients with reduced LVEFs
indicates increased LVEDP with highaccuracy both in sinus rhythm and in AF.

1. Not every patient can perform this maneuver
adequately. The patient must generate andsustain a sufficient increase in intrathoracic
pressure, and the examiner needs to maintainthe correct sample volume location between
the mitral leaflet tips during the maneuver.
2. It is difficult to assess if it is not standardized.

1. IVRT duration is in part affected by heart rate andarterial pressure.
2. More challenging to measure and interpret withtachycardia.

Journal of the American Society of Echocardiography
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Mitral E velocity

282 Nagueh et al

Table 2 Utility, advantages and limitations of variables used to assess LV diastolic function

3. It can be combined with LV end-systolicpressure to estimate the time constant of LV
relaxation (t).
4. It can be applied in patients with mitral stenosis
in whom the same relation with LV fillingpressures described above holds.
5. In patients with MR and in those after MV
replacement or repair, it can be combined with
TE-e0 to estimate LV filling pressures.

3. Results differ on the basis of using CW or PW
Doppler for acquisition.

A significant association is present between e0 and the 1. Feasible and reproducible.
time constant of
2. LV filling pressures have a minimal effect on e0 in
the presence of impaired LV relaxation.
LV relaxation (t) shown in both animals and3. Less load dependent than conventional bloodhumans.
pool Doppler parameters.
The hemodynamic determinants of e0 velocity include
LV relaxation, restoring forces and filling pressure.

1. Limited accuracy in patients with CAD andregional dysfunction in the sampled
segments, significant MAC, surgical rings orprosthetic mitral valves and pericardial disease.
2. Need to sample at least two sites with precise
location and adequate size of sample volume.
3. Different cutoff values depending on the samplingsite for measurement.
4. Age dependent (decreases with aging).

Mitral E/e0 ratio

e0 velocity can be used to correct for the effect of LV 1. Feasible and reproducible.
relaxation on mitral E velocity, and E/e0 ratio can be 2. Values for average E/e0 ratio < 8 usually indicate
used to predict LV filling pressures.
normal LV filling pressures, values > 14 havehigh specificity for increased LV fillingpressures.

1. E/e0 ratio is not accurate in normal subjects,
patients with heavy annular calcification,
mitral valve and pericardial disease.
2. ‘‘Gray zone’’ of values in which LV fillingpressures are indeterminate.
3. Accuracy is reduced in patients with CAD andregional dysfunction at the sampled segments.
4. Different cutoff values depending on the site used
for measurement.

TE-e0 time interval

Can identify patients with diastolic dysfunction due to 1. Ratio of IVRT to TE-e0 can be used to estimate LV
delayed onset of e0 velocity compared with onset offilling pressures in normal subjects andmitral E velocity.
patients with mitral valve disease.
2. TE-e0 can be used to differentiate patients withrestrictive cardiomyopathy who have a
prolonged time interval from those with
pericardial constriction in whom it is not
usually prolonged.

More challenging to acquire satisfactory signals withclose attention needed to location, gain, filter
settings as well as matching RR intervals.

LA maximum
volume index

LA volume reflects the cumulative effects of increased 1. Feasible and reproducible.
LV filling pressures over time. Increased LA volume 2. Provides diagnostic and prognostic information
is an independent predictor of death, heart failure,
about LV diastolic dysfunction and chronicity
of disease.
AF, and ischemic stroke.
3. Apical four-chamber view provides visual
estimate of LA and RA size which confirms LA
is enlarged.

1. LA dilation is seen in bradycardia, high-output
states, heart transplants with biatrial technique,atrial flutter/fibrillation, significant mitral valve
disease, despite normal LV diastolic function.
2. LA dilatation occurs in well-trained athletes who
have bradycardia and are well hydrated.
3. Suboptimal image quality, including LA
foreshortening, in technically challenging
studies precludes accurate tracings.
4. It can be difficult to measure LA volumes inpatients with ascending and descending aortic
aneurysms as well as in patients with large
interatrial septal aneurysms.
(Continued )Nagueh et al 283

Pulsed-wave
TDI-derived
mitral annular
early diastolicvelocity: e0

Journal of the American Society of Echocardiography
Volume 29 Number 4

shortens and its duration is inversely related to LV
filling pressures in patients with cardiac disease.

Variable

Utility and physiologic backgroundPulmonary veins:
S-wave velocity (sum of S1 and S2) is influenced bysystolic (S)changes in LAP, LA contractility, and LV and RV
velocity, diastolic
contractility.
(D) velocity,
D-wave velocity is mainly influenced by earlyand S/D ratio
diastolic LV filling and compliance and it changes
in parallel with mitral E velocity.
Decrease in LA compliance and increase in LAP isassociated with decrease in S velocity andincrease in D velocity.

Advantages

Limitations

1. Feasibility of recording PV inflow can be
1. Reduced S velocity, S/D ratio < 1, and systolic
suboptimal, particularly in ICU patients.
filling fraction (systolic VTI/total forward flow VTI)
< 40% indicate increased mean LAP in patients 2. The relationship between PV systolic filling fraction
and LAP has limited accuracy in patients with
with reduced LVEFs.
normal LVEF, AF, mitral valve disease and HCM.
2. In patients with AF, DT of diastolic velocity (D) in
pulmonary vein flow can be used to estimate
mean PCWP.

The time difference between duration of PV flow and 1. PV Ar duration > mitral A duration by 30 msec
mitral inflow during atrial contraction is associatedindicates an increased LVEDP.
with LV pressure rise because of atrial contraction 2. Independent of age and LVEF.
and LVEDP. The longer the time difference, the
3. Accurate in patients with MR and patientswith HCM.
higher LVEDP.

1. Adequate recordings of Ar duration may not be
feasible by TTE in several patients.
2. Not applicable in AF patients.
3. Difficult to interpret in patients with sinus
tachycardia or first-degree AV block with E andA fusion.

CW Doppler
TR systolic
jet velocity

A significant correlation exists between systolic PA
pressure and noninvasively derived LAP.
In the absence of pulmonary disease, increased
systolic PA pressure suggests elevated LAP.

Systolic PA pressure can be used as an adjunctive
parameter of mean LAP.
Evidence of pulmonary hypertension has prognostic
implications.

1. Indirect estimate of LAP.
2. Adequate recording of a full envelope is not always
possible, though intravenous agitated saline orcontrast increases yield.
3. With severe TR and low systolic RV-RA pressure
gradient, accuracy of calculation is dependent
on reliable estimation of RA systolic pressure.

CW Doppler PR
end-diastolicvelocity

A significant correlation exists between diastolic PA
pressure and invasively as well as noninvasively
derived LAP.
In the absence of pulmonary disease, increased
diastolic PA pressure is consistent withelevated LAP.

Diastolic PA pressure can be used as an adjunctive
parameter of mean LAP.
Evidence of pulmonary hypertension has prognostic
implications.

1. Adequate recording of a full PR jet envelope is notalways possible though intravenous contrast
increases yield.
2. Accuracy of calculation is dependent on thereliable estimation of mean RAP.
3. If mean PA pressure is >40 mm Hg or PVR>200 dynes$s$cm5, PA diastolic pressure ishigher by >5 mm Hg over mean PCWP.

Color M-mode
Vp: Vp, andE/Vp ratio

Vp correlates with the time constant of LV relaxation 1. Vp is reliable as an index of LV relaxation in patients 1. There are different methods for measuring mitral(t) and can be used as a parameter of LV relaxation.
with depressed LVEFs and dilated left ventricle
to-apical flow propagation.
E/Vp ratio correlates with LAP.
but not in patients with normal EFs.
2. In patients with normal LV volumes and LVEF but
2. E/Vp $ 2.5 predicts PCWP >15 mm Hg withelevated LV filling pressures, Vp can bereasonable accuracy in patients withmisleadingly normal.
depressed EFs.
3. Lower feasibility and reproducibility.
4. Angulation between M-mode cursor and flow
results in erroneous measurements.

AR, Atrial reversal velocity in pulmonary veins; PA, pulmonary artery; PN, pseudonormal; PR, pulmonary regurgitation; PV, pulmonary vein; PVR, pulmonary vascular resistance; RA, rightatrial; TDI, tissue Doppler imaging.

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April 2016

Ar-A duration

284 Nagueh et al

Table 2 (Continued )Nagueh et al 285

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Figure 2 Tissue Doppler recordings of septal mitral annular velocities. In (A), Doppler settings and sample volume location are
optimal, whereas in (B) the sample volume is placed in the ventricular septum (not annulus). Doppler setting are suboptimal in (C)with low gain and in (D) with high filter.

Figure 3 Tissue Doppler recordings of lateral mitral annular velocities. In (A), Doppler sample volume is located in part in LV cavity. In(B) the sample volume is in basal segment of lateral wall, in (C) the location is partly outside the heart altogether, and in (D) it is locatedin the left atrium above the mitral annulus.
function, LV GLS by speckle-tracking echocardiography (STE).
Because patients with reduced LVEFs also have impaired diastolic
function (examples shown in Figures 9–11 for heart failure with
reduced EF [HFrEF]), the evaluation has a different focus than inpatients with normal LVEF ($50%) (examples shown in

Figures 12–15 for HFpEF). The main reason for evaluating
diastolic function in patients with reduced EFs is to estimate LV
filling pressure. As in several other patient groups, it is important
to look for consistency between the different parameters. Whenusing such an integrated approach, a reliable estimate of LV

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286 Nagueh et al

Figure 4 The figure shows the three independent determinants of e0 , which are LV relaxation, restoring forces, andlengthening load. Rate of relaxation reflects decay of active
fiber force. Restoring forces which account for diastolic suction, are illustrated by an elastic spring which is compressed
to a dimension (Lmin) less than its resting length (L0) and recoils back to resting length when the compression isreleased. Lengthening load is the pressure in the left atrium
at mitral valve opening, which ‘‘pushes’’ blood into the left
ventricle and thereby lengthens the ventricle. The figure isbased on data from Opdahl et al.35

filling pressure can be achieved in most patients.67,68 Given thepresence of situations in which LAP and LVEDP are different
and because LAP is the pressure that relates better with mean
PCWP and thus pulmonary congestion symptoms at the time ofthe echocardiographic examination, the algorithm is presented
with the premise of estimating mean LAP. The approach starts
with mitral inflow velocities and is applied in the absence ofatrial fibrillation (AF), significant mitral valve disease (at least
moderate mitral annular calcification [MAC], any mitral stenosis
or mitral regurgitation [MR] of more than moderate severity,
mitral valve repair or prosthetic mitral valve), LV assist devices,left bundle branch block, and ventricular paced rhythm.
The proposed algorithm is based on expert consensus andhas not been validated. Because diastolic dysfunction is a resultof underlying myocardial disease in patients with reduced orpreserved LVEF, a rather similar approach can be considered inthese populations. When the mitral inflow pattern shows an E/
A ratio # 0.8 along with a peak E velocity of #50 cm/sec,
then mean LAP is either normal or low. The corresponding gradeof diastolic dysfunction is grade I. When the mitral inflow patternshows an E/A ratio $2, LA mean pressure is elevated and grade
III diastolic dysfunction is present. DT is usually short in thesepatients (<160 msec) but in some patients it can exceed
160 msec in the presence of an E velocity > 120 cm/sec as it
takes a longer time for a higher E velocity to decelerate. In this

Journal of the American Society of Echocardiography
April 2016

situation, the writing group recommends using only the E/A
ratio in the classification scheme. On the other hand, mitral
DT should be used for assessment of LV diastolic function inpatients with recent cardioversion to sinus rhythm who canhave a markedly reduced mitral A velocity because of LA stunning at the time of the echocardiographic examination, thus
leading to an E/A ratio $ 2 despite the absence of elevated LV
filling pressures (Figure 16). Of note, in young individuals(<40 years of age), E/A ratios > 2 may be a normal finding,51
and therefore in this age group other signs of diastolic dysfunction should be sought. Importantly, normal subjects have normal
annular e0 velocity which can be used to verify the presence of
normal diastolic function.
When mitral inflow shows an E/A # 0.8 and the peak E velocity is >50 cm/sec, or if the E/A ratio is >0.8 but <2, other signals
are necessary for accurate evaluation. We recommend thefollowing parameters: peak velocity of TR jet by CW Doppler
obtained from multiple views, E/e0 ratio and LA maximum volume index. A TR jet peak velocity > 2.8 m/sec supports the presence of elevated LV filling pressures, and the same conclusion canbe reached when E/e0 ratio is elevated. In patients in whom
one of the three main criteria is not available, the ratio of pulmonary vein peak systolic to peak diastolic velocity or systolic timevelocity integral to diastolic time-velocity integral < 1 supports
the presence of elevated LV filling pressures. In healthy young
people (<40 years of age), pulmonary venous S/D ratio can be<1, but the normality of findings including mitral annular e0 velocity and LA maximum volume index should rarely cause confusion. Importantly, among the above mentioned parameters,
the peak velocity of TR jet by CW Doppler provides a direct estimate of PASP when combined with right atrial pressure.
Because it is uncommon to have primary pulmonary arterial disease coexisting with HFrEF, an elevated PASP supports the presence of elevated LAP.
If all three parameters are available for interpretation and only
one of three meets the cutoff value, then LAP is normal and there
is grade I diastolic dysfunction. If two of three or all three available
parameters meet the corresponding cutoff values then LAP iselevated and there is grade II diastolic dysfunction. If only one
parameter is available, LAP and grade of diastolic dysfunction
should not be reported and likewise if there is discrepancy between the only two available parameters. The assessment of LV
filling pressures is important in patients with HFrEF as it can successfully guide medical treatment.69
In patients with preserved EFs, the same initial evaluation ofclinical presentation and 2D and color Doppler echocardiographic findings such as LVEF, regional wall motion abnormalities, LV hypertrophy, LA maximum volume index andsignificant mitral valve disease is performed to aid the assessmentof LV diastolic function. Cardiac structural as well as functional
information should be used when assessing diastolic function inpatients with preserved EFs. In particular an enlarged LA that isclearly larger than the right atrium in the optimally aligned apicalfour-chamber view is strongly suggestive of chronically elevated
LV filling pressure, provided conditions such as anemia, atrial arrhythmias and mitral valve disease can be excluded. Athletes may
also have enlarged atria without increased LV filling pressures.
However, a normal LA volume index does not exclude the presence of diastolic dysfunction when other findings are consistent
with its presence. In particular, a normal LA volume is often
noted in patients in the earliest stage of diastolic dysfunction

Nagueh et al 287

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Volume 29 Number 4

Figure 5 Valsalva maneuver in a patient with grade II diastolic dysfunction. At baseline, E/A ratio is 1.3 (left) and decreases to 0.6(impaired relaxation pattern) with Valsalva.

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to be of value in identifying patients with HFpEF.45,70,71 Cutoff
values for elevated LAP are average E/e0 > 14, LA maximum
volume index > 34 mL/m2 and TR jet > 2.8 m/sec. Because
the pulmonary venous S/D ratio often is <1 in healthy young
individuals, this index is of little value in patients with normal
LVEF.
When two of three or all three variables meet the cutoff
threshold, mean LAP is elevated and there is grade II diastolic
dysfunction. Conversely, if two of three or all three variables do
not meet the cutoff threshold, then LAP is normal and grade I diastolic dysfunction is present. If one of two available parameters
gives opposite information to the other signal, or if there is only
one parameter with satisfactory quality for analysis, neither LAP
nor diastolic grade should be reported. In the presence of an E/
A ratio $ 2, grade III diastolic dysfunction is present. Table 4 presents a summary of the expected findings for the different gradesof diastolic dysfunction.
Figure 6 Continuous recording of mitral inflow during standardized Valsalva maneuver for 10 sec showing the decrease in E/Aratio with straining, which is consistent with elevated LV fillingpressures.

and in situations with an acute increase in LV filling pressures. For
LV hypertrophy (most reliably confirmed by LV mass that exceeds gender-specific normal range53), the finding of pathologic
LV hypertrophy is consistent with diastolic dysfunction.
Elevated PASP calculated from the TR jet (Figure 17) is strongly
suggestive of elevated LV filling pressure unless pulmonary parenchymal or vascular disease is known to be present.
Similar to patients with depressed EFs, LAP is likely normal in
the presence of an E/A ratio # 0.8 along with a peak E velocity
of #50 cm/sec in patients with structural heart disease and normal
EF. The corresponding grade of diastolic dysfunction is grade I. In
patients with an E/A # 0.8 along with a peak E velocity of>50 cm/sec, or an E/A ratio > 0.8 but < 2, additional parameters
should be examined. As in patients with depressed LVEFs, theseinclude LA maximum volume index, peak velocity of TR jet andaverage E/e0 ratio. Importantly, all three indices have been shown

Key Points
1. In patients with reduced LVEFs, transmitral inflow pattern is usually sufficient to
identify patients with increased LAP and DT of mitral E velocity is an important predictor of outcome.
2. In patients with preserved LVEFs, several parameters, including 2D variables, areoften needed to estimate LAP.
3. In patients with depressed EFs and in patients with normal EFs and myocardial disease, if E/A ratio is #0.8 along with a peak E velocity of #50 cm/sec, then mean
LAP is either normal or low and patient has grade I diastolic dysfunction.
4. In patients with depressed EFs and in patients with normal EFs and myocardial disease, if E/A ratio is $ 2, LA mean pressure is elevated and grade III diastolic dysfunction is present. DT is usually short in patients with HFrEF and restrictive filling pattern(<160 msec). However, in patients with HFpEF, DT can be normal despite elevated LV
filling pressures.
5. In patients with depressed EFs and in patients with normal EFs and myocardial
disease, E/A ratio # 0.8 along with a peak E velocity of >50 cm/sec, or an E/Aratio > 0.8 but < 2, additional parameters are needed. These include peak TR velocity, E/e 0 ratio and LA maximum volume index. Their cutoff values toconclude elevated LAP are peak velocity of TR jet >2.8 m/sec, average E/e0 ratio>14, and LA maximum volume index > 34 mL/m 2 . If more than half or allof the variables meet the cutoff values, then LAP is elevated and grade II diastolic dysfunction is present. If only one of three available variables meetsthe cutoff value, then LAP is normal and grade I diastolic dysfunction is present. In case of 50% discordance or with only one available variable, findings
are inconclusive to estimate LAP.
6. In patients with depressed LVEFs, pulmonary vein S/D ratio may be used if oneof the three main parameters is not available. A ratio < 1 is consistent withincreased LAP.

0/165 (0.0)
SPAP, Systolic pulmonary artery pressure.
*LA volume index > 34 mL/m2 by biplane Simpson method (adapted from Caballero et al.52).

0/165 (0.0)
1/129 (0.8)

0/129 (0.0)
0/294 (0.0)

1/294 (0.3)
0/33 (0.0)

0/33 (0.0)
0/24 (0.0)

0/24 (0.0)

0/74 (0.0)
0/57 (0.0)
0/131 (0.0)
0/106 (0.0) 0/48 (0.0) 0/58 (0.0)
SPAP > 45 mm Hg

LA volume index >34 mL/m2 (*)

IV. CONCLUSIONS ON DIASTOLIC FUNCTION IN THE
CLINICAL REPORT

0/57 (0.0)

0/74 (0.0)
0/57 (0.0)
0/131 (0.0)
1/106 (0.9) 1/48 (2.1) 0/58 (0.0)
SPAP > 36 mm Hg

0/57 (0.0)

2/234 (0.9)

31/294 (10.5) 13/128 (10.2) 18/166 (10.8)
1/26 (3.8)
2/24 (8.3)
11/76 (14.5)
7/51 (13.7)
10/117 (8.5) 4/53 (7.5) 6/64 (9.4) 18/127 (14.2)

3/50 (6.0)

2/236 (0.8)
3/192 (1.6)

1/187 (0.5)
3/421 (0.7)

5/428 (1.2)
1/43 (2.3)

0/42 (0)0/36 (0)2/38 (5.3)

2/108 (1.9)

0/78 (0)1/109 (0.9)

3/184 (1.6)
0/84 (0)1/76 (1.3)

2/185 (1.1)
0/84 (0)0/159 (0)Lateral E/e0 > 13

0/75 (0)0/162 (0)Septal E/e0 > 15

0/78 (0)1/76 (1.3)

3/81 (3.7)

2/233 (0.9)
2/187 (1.1)
4/420 (1.0)
0/42 (0)1/36 (2.8)
1/78 (1.3)
2/108 (1.9)

9/80 (11.3) 21/112 (18.8) 41/79 (51.9) 17/36 (47.2) 24/43 (55.8) 74/438 (16.9) 28/192 (14.6) 46/246 (18.7)

18/246 (7.3)
10/192 (5.2)
5/36 (13.9) 10/43 (23.3) 28/438 (6.4)
15/79 (19.0)
7/112 (6.3)
4/80 (5.0)

1/76 (1.3)
3/184 (1.6)
0/83 (0)0/75 (0)0/158 (0)Average (septallateral) E/e0 > 14

Lateral e < 10 cm/sec 3/167 (1.8) 2/76 (2.6) 1/91 (1.1) 30/192 (15.6)

02/167 (1.2) 1/76 (1.3) 1/91 (1.1) 11/192 (5.7)

38/193 (19.7) 13/80 (16.3) 25/113 (22.1) 46/83 (55.4) 22/39 (56.4) 24/44 (54.5) 86/446 (19.3) 37/198 (18.7) 49/248 (19.8)
2/170 (1.2) 2/79 (2.5) 0/91 (0)Septal e0 < 8 cm/sec

Parameter

Journal of the American Society of Echocardiography
April 2016

Lateral e0 < 8 cm/sec

Male(N = 198)
n/N (%)
Male(N = 39)n/N (%)
Total(N = 83)n/N (%)
Female(N = 114)
n/N (%)
Male(N = 80)n/N (%)
Total(N = 172)n/N (%)

Male(N = 79)
n/N (%)

Female(N = 93)n/N (%)

Total(N = 194)
n/N (%)

40–60 y20–40 yTable 3 Proportion of normal subjects with abnormal LA volume index and Doppler velocities$60 yFemale(N = 44)n/N (%)

Total(N = 449)
n/N (%)

Global cohort

Female(N = 251)
n/N (%)

288 Nagueh et al

Although several invasive parameters of LV diastolic function such as
the time constant of LV relaxation (t) or LV chamber stiffness may beinferred or derived from Doppler echocardiographic findings, the association between invasive and noninvasive parameters is not perfect.
Furthermore to date, there is no specific targeted treatment for theseabnormalities that has proved useful in clinical trials. In comparison,
specific comments on the status of LV filling pressures are more helpful to the referring physician in terms of narrowing a differential diagnosis. The conclusion could be one of three options: normal, elevatedor cannot be determined (Table 5 shows examples from several laboratories on reporting findings about LV diastolic function). The
writing group believes it is important to include this conclusion
when feasible, particularly in patients referred with symptoms of dyspnea or diagnosis of ‘‘heart failure.’’ In addition, the grade of LV diastolic dysfunction should be included in the reports along with theestimated LV filling pressures. The rationale for this recommendation
comes from several single center and epidemiologic studies showing
the independent and incremental prognostic information provided by
LV diastolic dysfunction grade in several settings including HFrEF,
HFpEF and acute myocardial infarction.72-87 Finally, when feasible,
comparison with previous studies and comments about changes indiastolic dysfunction grade or lack thereof, should be added as thiscan inform treatment decisions and predict future events ofadmissions for heart failure and total mortality.88-93 Consideration
may be given to diastolic stress testing in borderline cases (seesection on diastolic stress test). Furthermore, right heart
catheterization may be needed in difficult cases to determine if
PCWP is elevated or if there is a discrepancy between rightventricular (RV) and LV filling pressures indicating the presence ofpulmonary vascular disease.

Key Points
1. Conclusions on LV diastolic function should be included routinely in reports when
feasible, particularly in patients referred with symptoms of dyspnea or diagnosis ofheart failure.
2. The report should comment on LV filling pressures and the grade of LV diastolic
dysfunction. If available, comparison with previous studies is encouraged to detectand comment on changes in diastolic function grade over time.

V. ESTIMATION OF LV FILLING PRESSURES IN SPECIFICCARDIOVASCULAR DISEASESThe following sections discuss the pathophysiology of disorders withabnormal cardiac structure, valve disease and atrial arrhythmias,
which modify the relationship between indices of diastolic function
and LV filling pressure (Table 6). In some of the disorders the algorithm outlined above has significant limitations. PASP estimatedfrom the TR jet, however, is a valid index of LAP in all conditions
mentioned, provided there is no evidence of pulmonary vascular orparenchymal disease. In the absence of AF or atrial flutter, mitral valve
disease or heart transplantation, an increased LA volume with anormal appearing right atrial size is a robust indicator of elevated
LAP. One significant limitation to this marker is if heart failure therapy
has resulted in normalization of pressures with persistent LA dilatation. In this setting, the presence of increased TR velocity > 2.8 m/
sec is suggestive of elevated LAP.

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Figure 7 Example of normal findings from a young subject. Left shows normal LV size in parasternal long-axis view, with a normal
mitral inflow pattern and E/A ratio > 1 in middle panel. Lateral e0 velocity is normal at 12 cm/sec (left).
A. Hypertrophic Cardiomyopathy
A comprehensive approach is recommended for assessment of LV
diastolic function and filling pressures in patients with hypertrophic
cardiomyopathy (HCM) (example shown in Figure 18). This includes
E/e0 ratio, LA volume index, pulmonary vein atrial reversal velocity,and peak velocity of TR jet by CW Doppler.100-106,113,114 In general,
individual variables when used alone, have modest correlations with
LV filling pressures in patients with HCM, likely related to variability
in phenotype, muscle mass, amount of myocardial fiber disarray,and obstructive versus nonobstructive physiology. This leads todifferent combinations of altered relaxation and compliance andresultant variations of mitral inflow patterns. Aside from assessmentof LV filling, 2D and Doppler indices of LV diastolic function
provide incremental prognostic information in this population. In
children with HCM, septal E/e0 ratio predicted adverse outcomes
including death, cardiac arrest and ventricular tachycardia.102 There
are similar results in adults with HCM, showing worse outcomes in patients with an enlarged left atrium, abnormal diastolic function detected by E/e0 ratio, or restrictive LV filling.104-106,113,114
More recently, studies using STE have reported the association between LV systolic and diastolic strain, LA strain and LV diastolic function. Furthermore, they have provided mechanistic insights linking LV
function, including torsion and untwisting, to exercise tolerance.115-120
There is growing interest in studying the relation between early
diastolic vortices and LV filling in HCM.121 While promising, additional
studies and technical developments are needed before they can beendorsed as routine measurements in patients with HCM.

Key Points
1. Variables recommended for evaluation of diastolic function in patients with HCM areaverage E/e0 ratio (>14), LA volume index (>34 mL/m2), pulmonary vein atrial reversal
velocity (Ar-A duration $ 30 msec), and peak velocity of TR jet by CW Doppler(>2.8 m/sec). The parameters can be applied irrespective of the presence or absenceof dynamic obstruction and MR, except for patients with more than moderate MR,
in whom only Ar-A duration and peak velocity of TR jet are still valid.
2. If more than half of the variables (total available variables three or four) meet the cutoff values, then LAP is elevated and grade II diastolic dysfunction is present. If <50%of the variables (total available variables three or four) meet the cutoff values, then
LAP is normal and grade I diastolic dysfunction is present. In case of 50% discordancewith two or four available variables, findings are inconclusive to estimate LAP. Estimation of LAP is not recommended if there is only parameter with a satisfactory signal.
3. Grade III diastolic dysfunction is present in the presence of a restrictive filling pattern
and abnormally reduced mitral annular e0 velocity (septal <7 cm/sec, lateral <10 cm/
sec).

B. Restrictive Cardiomyopathy
Restrictive cardiomyopathies are composed of a heterogeneousgroup of heart muscle diseases including idiopathic restrictive cardio-

myopathy, cardiac amyloidosis, and sarcoidosis.122 In the earlier
stages of cardiac amyloidosis, diastolic function can vary from grade
1 diastolic dysfunction with impaired relaxation and normal LV fillingpressures to grade 2 (pseudonormalization). In later stages, grade 3
diastolic dysfunction occurs when LV relaxation is impaired alongwith markedly elevated LV filling pressures.107 There has been a
gradual evolution of the diastolic function techniques applied instudying these patients, initially using mitral inflow and pulmonaryvein flow, to tissue Doppler and now STE, which can be used to measure strain and strain rate. The advanced stages of restrictive cardiomyopathy, are characterized by typical restrictive physiology with a
dip and plateau pattern for early diastolic LV pressure changes withtime, mitral inflow E/A ratio > 2.5, DT of E velocity < 150 msec, isovolumic relaxation time (IVRT) < 50 msec,108,123 decreased septal
and lateral e0 velocities (3–4 cm/sec),124,125 but with a higher laterale0 compared with septal e0 velocity (unlike constrictive pericarditis,in which septal e0 is often higher, or annulus reversus),126 E/e0 ratio >14, as well as a markedly increased LA volume index (>50 mL/m2)127,128. Figure 19 shows a validated algorithm from the Mayo
Clinic comparing constrictive pericarditis with restrictive cardiomyopathy. The presence of a normal annular e0 velocity in a patient referredwith heart failure diagnosis should raise suspicion of pericardialconstriction.
Grade 3 diastolic dysfunction is associated with a pooroutcome in patients with restrictive cardiomyopathy.109 It is
important to make the distinction between restrictive LV filling,which can occur with other diseases such as coronary artery disease, dilated cardiomyopathy and HCM, and restrictive cardiomyopathy. STE of LV myocardium in patients with cardiac
amyloidosis has shown a distinctive phenotype of apical sparing(Figure 20) using a polar plot of LV longitudinal strain comparedwith hypertensive heart disease, HCM, and aortic stenosis.129
Similar to tissue Doppler imaging, the ratio of LV free wall strain
to LV septal strain by STE is about 1 in patients with restrictive
cardiomyopathy, whereas it is usually <1 in patients withconstriction because of less deformation of the LV anterolateralwall compared with the LV septum.130

Key Points
1. Patients with early disease usually have grade I diastolic dysfunction that progresses
to grade II as the severity of the disease advances.
2. In patients with advanced disease, grade III diastolic dysfunction is present and ischaracterized by mitral inflow E/A ratio > 2.5, DT of E velocity < 150 msec, IVRT <50 msec, and decreased septal and lateral e0 velocities (3–4 cm/sec).
3. Patients with constrictive pericarditis usually have septal e0 velocity higher thanlateral e0 velocity, or annulus reversus, and E/e0 ratio should not be used to estimate
LV filling pressures in patients with constrictive pericarditis.

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A

In patients with normal LV EF
1-Average E/e’ > 14
2-Septal e’ velocity < 7 cm/s or
Lateral e’ velocity <10 cm/s
3-TR velocity > 2.8 m/s
4-LA volume index >34ml/m2<50%
positive

Normal Diastolic
function50%
positive>50%
positive

Indeterminate

DiastolicDysfunction

B

Mitral Inflow
E/A ≤ 0.8 + E > 50 cm/s
or
E/A > 0.8 - <2

E/A ≤ 0.8 + E ≤ 50 cm/s

E/A ≥ 23 criteria to be evaluated*

2 of 3 or 3 of 3
Negative

1-Average E/e’ > 14
2-TR velocity > 2.8 m/s
3-LA Vol. index>34ml/m2

2 of 3 or 3 of 3
Positive

When only 2 criteria are available
2 negative

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Normal LAP
Grade I Diastolic
Dysfunction

1 positive and1 negative

Cannot determine
LAP and Diastolic
Dysfunction
Grade*

2 positive↑ LAP
Grade II Diastolic
Dysfunction↑ LAP
Grade III Diastolic
Dysfunction

If Symptomatic
Consider CAD, orproceed to diastolic
stress test(* : LAP indeterminate if only 1 of 3 parameters available. Pulmonary vein S/D ratio <1 applicable to conclude elevated LAP inpatients with depressed LV EF)

Figure 8 (A) Algorithm for diagnosis of LV diastolic dysfunction in subjects with normal LVEF. (B) Algorithm for estimation of LV fillingpressures and grading LV diastolic function in patients with depressed LVEFs and patients with myocardial disease and normal LVEF
after consideration of clinical and other 2D data.
C. Valvular Heart Diseasei. Mitral Stenosis. In this condition, transmitral blood flow velocities and mitral annular dynamics are largely determined by the degree of valvular disease and therefore of limited value as indicators

of LV disease. Typically, patients with mitral stenosis have normal
or reduced LV diastolic pressures, except for the rare occurrenceof coexisting myocardial disease. The same hemodynamic findings
are present in patients with other etiologies of LV inflow obstruction, such as prosthetic mitral valve, large LA tumor, cor triatriatum

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Figure 9 LV and RV pressure recordings along with mitral
inflow and tricuspid inflow obtained from a patient withdilated cardiomyopathy. LV pressure recordings are shown
to the left with red arrows denoting LV pre-A pressure and
LVEDP. Both are increased with LV pre-A pressure at
19 mm Hg and LVEDP at 30 mm Hg. Mitral inflow (top) shows
restrictive filling pattern. In comparison, RV pressure recordings (right) show RV pre-A pressure at 8 mm Hg and RV
end-diastolic pressure (RVEDP) at 12 mm Hg. The corresponding tricuspid inflow pattern (bottom) shows an impaired
relaxation pattern. In the presence of normal LV and RV fillingpressures and myocardial dysfunction, both tricuspid inflow
and mitral inflow reveal an impaired relaxation pattern.
Thus, the presence in this case of an impaired relaxation
pattern for tricuspid inflow and a restrictive filling pattern for
mitral inflow supports the conclusion that LV filling pressuresare elevated. Abbreviations as in other figures.

sinustrum, and congenital mitral valve stenosis. Nevertheless, asemiquantitative estimation of instantaneous LAP can be provided
in early and late diastole by Doppler variables. The shorter the
IVRT (corresponds to time interval between second heart soundand mitral valve opening snap) and the higher the peak E-wave velocity, the higher the early diastolic LAP. LAP is significantly
elevated at end-diastole if the mitral A velocity remains >1.5 m/
sec at this point.
The time interval between onset of mitral E velocity and annulare0 velocity can be applied to estimate LV filling pressures in patientswith mitral valve disease. In the presence of impaired LV relaxation, the e0 velocity is not only reduced but also delayed suchthat it occurs at the LA-LV pressure crossover point. In comparison, mitral E velocity occurs earlier with elevated LAP. Thus thetime interval between the onset of mitral E velocity and annulare0 velocity is prolonged and can correct for the effect of LV relaxation on IVRT. IVRT/TE–e0 ratio correlates well with mean PCWP
and LAP in patients with mitral stenosis (Figure 21). However,the E/e0 ratio is not useful.110
ii. MR. Primary MR leads to LA and LV enlargement and an increase in the compliance of both chambers, which attenuates
the increase in LAP. If LA compensation is incomplete, mean
LAP and right-sided pressures increase, which is related to theadditional regurgitant volume, not to LV dysfunction. With LV diastolic dysfunction, a myocardial component of increased filling

Nagueh et al 291

pressures is added over time. The sequence is opposite to thatseen in primary myocardial disease such as dilated cardiomyopathy, which leads to increased filling pressures earlier on and laterto functional MR. Therefore, in patients with secondary MR,
echocardiographic correlates of increased filling pressures reflect
the combination of both myocardial and valvular disorders.
Moderate and severe MR usually lead to an elevation of peak E
velocity and a decrease in pulmonary venous systolic velocity
and thus the S/D ratio in pulmonary venous flow. In severeMR, pulmonary venous flow reversal can be seen in late systole.
Thus, MR per se can induce changes in transmitral and pulmonary
venous flow patterns resembling advanced LV dysfunction, withthe possible exception of the difference in duration between Ar
and mitral A velocity.111 MR velocity recording by CW Doppler
can provide a highly specific, though not sensitive, sign ofincreased LAP with early peaking and usually a reduced LV pressure–LAP gradient. The utility of E/e0 in predicting LV filling pressures in the setting of moderate or severe MR is more
complex.112,131,132 In patients with depressed EFs, an increased
E/e0 ratio has a direct significant relation with LAP and predicts
hospitalizations and mortality.112,132 E/e0 does not appear to be
useful in patients with primary MR and normal EFs, thoughsome investigators have noted a good correlation between E/e0
ratio and mean wedge pressure as well as PASP in thispopulation.133 IVRT and the ratio of IVRT to TE-e correlate reasonably well with mean PCWP, regardless of EF.110 An IVRT/TE-eratio < 3 readily predicts PCWP > 15 mm Hg in this patient subgroup. In patients with AF and MR, use of matched intervals(necessitating acquisition of a large number of cycles) or use of‘‘index beats’’ is necessary.134 It is challenging to assess LV relaxation and LV filling pressures after mitral valve surgery-repair or
replacement, although time intervals and PA pressures could beof value.
iii. MAC. MAC frequently accompanies hypertensive heart disease,aortic sclerosis, coronary artery disease and chronic kidney disease
and is prevalent in elderly patients. In patients with moderate to severe MAC, mitral orifice area is decreased, leading to increased diastolic transmitral velocities, while lateral or posterior e0 may bedecreased due to restriction of the posterior mitral leaflet excursion.135 Thus, an increase in E/e0 ratio occurs due to the mechanicaleffect of mitral calcification. Since underlying conditions such as hypertension may also cause diastolic dysfunction, separation of the effect of mitral calcification from that of LV diastolic dysfunction on E/e0
ratio may not be possible in the individual patient. It is not known if
septal e0 velocity or myocardial velocities distal to annular calcification
can be of value in these patients.
iv. Aortic Stenosis and Regurgitation. There are usually nomajor challenges to the application of the guidelines in patientswith aortic stenosis, except for the coexistence of moderate to severe MAC, for which the limitations noted in the previous section
apply. For patients with severe aortic regurgitation (AR), the AR jet
can interfere with the recording of mitral inflow velocities andcareful positioning of the sample volume is needed to avoid
contamination with the AR jet. In severe acute AR, the presenceof abbreviated LV diastolic filling period, premature closure of
the mitral valve, and diastolic MR indicate the presence of elevated
LV filling pressures. In chronic severe AR, the mitral inflow patternoften shows predominant early diastolic filling with short DT of
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Figure 11 Septal tissue Doppler velocities from a patient with
HFrEF and ventricular dyssynchrony. Mitral annular e0 (early diastolic annular velocity) should be distinguished from thebiphasic velocity during isovolumic relaxation (IVR) period.
Mitral annular late diastolic velocity (a0 ) follows the ‘‘P’’ wave.
Isovolumic contraction velocity (IVC) is biphasic. Systolic ejection velocity (s0 ) follows IVC velocity and precedes IVR velocity.

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Figure 10 Mitral inflow (left) and pulmonary venous flow (right) from a patient with HFrEF. Notice the increased E/A ratio >2 andreduced S/D ratio in pulmonary venous flow. Both findings are consistent with increased LAP in this patient population.

Figure 13 Mitral inflow from a patient with hypertensive heartdisease with normal EF. Patient has LV hypertrophy and amoderately enlarged left atrium. Mitral inflow shows pseudonormal LV filling pattern consistent with elevated LV filling pressuresand grade II diastolic dysfunction.
estimation of LV filling pressures in patients with chronic severe
AR. In patients with AR, the presence of LA enlargement, average
E/e0 ratio > 14, and TR peak velocity > 2.8 m/sec support thepresence of increased LV filling pressures.

Key Points

Figure 12 (Left) Mitral inflow from a patient with HFpEF. Mitral
inflow pattern is consistent with elevated LV filling pressures.
Notice the abbreviated mitral A velocity with short duration.
DT of mitral E velocity (Mdt) measured at 200 msec. This isseen in patients with markedly delayed LV relaxation such that
LV diastolic pressure continues to decline after mitral valve
opening. (Right) Pulmonary venous flow from the same patient.
Notice the decreased S/D ratio and the increased amplitude andvelocity of Ar signal consistent with increased LVEDP. Abbreviations as in other figures.

1. Mitral stenosis renders assessment of LV diastolic function more challenging, but
IVRT, TE-e0 , and mitral inflow peak velocity at early and late diastole can be of value
in the semiquantitative prediction of mean LAP.
2. The time interval Ar-A and IVRT/TE-e0 ratio may be applied for estimation for prediction of LV filling pressures in patients with MR and normal LVEF, whereas E/e0 ratio
may be considered only in patients with MR and depressed EF.
3. The guidelines in patients without valvular heart disease can be applied to patientswith aortic stenosis, irrespective of severity of valvular stenosis. This excludes patients with heavy MAC.
4. In patients with severe AR be it acute or chronic, premature closure of mitral valve,
diastolic MR, LA enlargement, average E/e0 ratio > 14, and TR peak velocity >2.8 m/sec are consistent with elevated LV filling pressures.

D. Heart Transplantation
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Figure 14 Mitral inflow (left) and IVRT (right) from another patient with HFpEF and heart rate 60 beats/min. E velocity was 96 cm/sec
with A velocity of 65 cm/sec. Mid-diastolic flow (L velocity) is present because of the slow and impaired LV relaxation and theincreased LAP. The arrows in the right panel point to IVRT between aortic valve closure and mitral valve opening. IVRT was shortat 48 msec consistent with increased LAP.

Figure 15 L velocity from a patient in sinus rhythm and increased LAP. Notice the presence of L velocity in mitral inflow and septal
tissue Doppler signals (arrows).

function more difficult. First, the donor heart is denervated,leading to sinus tachycardia with reduced heart rate variability.136 In turn, sinus tachycardia results in fusion of mitral
E and A velocities. The biatrial surgery technique usually resultsin two intact SA nodes beating at different rates (donor and remaining right atrial tissue from recipient heart) which can eachaffect mitral inflow causing beat to beat variability in mitral E
and A velocities. Furthermore, atrial function can be impaired
because of the midatrial anastomoses between the donor andthe recipient hearts. In comparison, the bicaval surgery technique may not impede atrial function.137 Pulmonary venous
flow is usually not helpful in assessing LV diastolic function
and filling pressures. The contraction of the remnant recipientatrial tissue interacts with the systolic pulmonary forward flow
component when it occurs during systole and can lead to lower
S velocity, whereas pulmonary vein Ar velocity can bemarkedly increased if recipient atrial contraction occurs at
end-diastole.
A restrictive appearing filling pattern in patients with preserved EFs
is a common finding after heart transplantation and is observed in patients with normal LV diastolic function as donor hearts are usually obtained from healthy young individuals.138 It is most pronounced in
the early weeks after surgery and can change at follow-up.139,140
While LV diastolic pressures can be normal at rest, a large increase
in LVEDP has been noted during exercise.141
Similar considerations as described above also exist for e0 velocity
as it is influenced by translational motion of the heart. Of
note, myocardial tissue velocities are lowest early after surgery andtend to increase during the following weeks and months, thoughsome studies noted that they were reduced 1 year after transplantation compared with a normal population.142-146 LV diastolic
dysfunction has often been described as a sensitive sign of early

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Figure 16 LA stunning after cardioversion. On the day of the cardioversion, LA stunning leads to markedly reduced mitral A velocity of
19 cm/sec and an apparent ‘‘restrictive LV filling’’ on the basis of mitral E/A ratio. Three days later, LA function improves withincreased A velocity and a decreased E/A ratio consistent with impaired LV relaxation but normal LV filling pressures.

Figure 17 TR velocity (3.3 m/sec) by CW Doppler (left) and hepatic venous flow (right) from a patient with HFpEF. RV–to–rightatrial pressure gradient was 43 mm Hg and hepatic venous flow showed predominant forward flow during diastole (D), consistent with elevated right atrial pressure (10–15 mm Hg). Thus, PASP was estimated at 53 to 58 mm Hg. In normal elderly subjects
without cardiac disease, predominant forward flow in hepatic veins occurs during systole. As right atrial mean pressure increases, flow pattern shifts so most flow occurs during diastole. Furthermore, the atrial reversal signal (Ar) that occurs becauseof right atrial contraction generating a positive pressure gradient between the right atrium and the hepatic veins increases inamplitude and duration with increasing RA pressure as seen in this recording. (Nagueh SF, Kopelen HA, Zoghbi WA. Relationof mean right atrial pressure to echocardiographic and Doppler parameters of right atrial and right ventricular function. Circulation 1996;93:1160–9; Rudski LG, Lai WW, Afilalo J, et al. Guidelines for the echocardiographic assessment of the right heart inadults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, aregistered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr 2010;23:685–713).

graft rejection as myocardial edema causes increased diastolic stiffness
and filling pressures in the presence of a normal EF (Figure 22). Lateron, myocardial fibrosis seen with chronic graft rejection can lead to a

restrictive LV filling pattern and markedly reduced annular velocities(Figure 23). However, no single diastolic parameter appears reliable
enough to predict graft rejection.146 As in other diseases, PASP

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Table 4 LV relaxation, filling pressures and 2D and Doppler
findings according to LV diastolic function
NormalGrade I

Grade II

Grade III

LV relaxation

Normal Impaired

Impaired

Impaired

LAP

Normal Low or normal ElevatedElevated

Mitral E/A ratio

$0.8

#0.8

>0.8 to <2>2

Average E/e0 ratio

<10

<10

10–14

>14

Peak TR velocity(m/sec)

<2.8

<2.8

>2.8

>2.8

LA volume index

Normal Normal or
increased

Increased Increased

Table 5 Examples of conclusions on LV diastolic function
from clinical laboratories
Example 1 (conclusion would
contain an item from each of
1, 2, and 3)

1. LV relaxation impaired or
normal
2. LV filling pressures normal,
elevated or borderline
elevated
3. Grade I diastolic dysfunction
or grade II diastolic
dysfunction or grade III
diastolic dysfunction

Example 2 (conclusion would
contain one of the six options
shown to the right)

a. Normal diastolic function
b. Impaired LV relaxation,
normal LAP
c. Impaired LV relaxation, mildly
elevated LAP
d. Impaired LV relaxation,
elevated LAP
e. Restrictive LV filling pattern,indicating markedly
elevated LAP
f. Indeterminate

Example 3 (conclusion would
contain one of the six options
shown to the right)

a. Normal diastolic function
b. Impaired LV relaxation,
normal LAP
c. Impaired LV relaxation,
increased LVEDP
d. Impaired LV relaxation,
elevated LAP
e. Restrictive LV filling pattern,indicating markedly
elevated LAP
f. Indeterminate

Example 4 (conclusion would
contain one of the five options
shown to the right)

1. Normal diastolic function andfilling pressure
2. Grade 1 (impaired relaxation
with low to normal fillingpressure)
3. Grade 2 (moderate increasein filling pressure)
4. Grade 3 (marked elevation in
filling pressure)

Example 5 (conclusion would
contain one of the three
options shown to the right)

1. Increased filling pressure
2. Normal filling pressure
3. Constrictive pericarditis

Example 6 (conclusion would
contain one of the three
options shown to the right)

1. Findings consistent withdiastolic dysfunction
2. Findings suggestive of
probable diastolic
dysfunction
3. Findings raise the possibilityof diastolic dysfunction.

estimation using the TR jet can be helpful as a surrogate measurementof mean LAP in the absence of pulmonary disease.

Key Points
1. A restrictive appearing filling pattern in patients with preserved EFs is a common
finding after heart transplantation and is observed in patients with normal LV diastolic function as donor hearts are usually obtained from healthy young individuals.
2. No single diastolic parameter appears reliable enough to predict graft rejection. PASP
estimation using the TR jet can be helpful as a surrogate measurement of mean LAP in
the absence of pulmonary disease.

E. Atrial Fibrillation
LV diastolic dysfunction causes LA dilatation, which can lead to
AF,147-149 and the presence of AF is not uncommon in patientswith heart failure. In patients with AF, Doppler assessment of LV
diastolic function is limited by the variability in cycle length, theabsence of organized atrial activity, and the frequent occurrenceof LA enlargement regardless of filling pressures. In general, when
LVEF is depressed in patients with AF, mitral DT (#160 msec) has
reasonable accuracy for the prediction of increased LV diastolicpressures and adverse clinical outcomes.94,95 Other Doppler
measurements that can be applied include peak acceleration rateof mitral E velocity ($1,900 cm/sec2), IVRT (#65 msec), DT of
pulmonary venous diastolic velocity (#220 msec), E/mitral Vp(E/Vp; $1.4), and E/e0 ratio ($11).43,94-96 Similar to sinus
rhythm, the time interval between onset of mitral E and annular e0
velocity could be measured. The delay in annular e0 velocity
occurs in the setting of impaired LV relaxation and whencombined with ‘‘IVRT-IVRT/TE-e’’ ratio can be used to predict LV
filling pressures.150,151
It is critical to average several cardiac cycles and to use matched
RR intervals for both E and e0 velocities. This often poses important
limitations to the routine application of these measurements inclinical practice. Recently the simultaneous recording of E and e0
velocities using a dual Doppler probe has made it possible toanalyze both the peak velocity as well as the timing of mitral E
and annular e0 velocities from the same cardiac cycle, which led
to improved accuracy in the estimation of LV filling pressure inthis patient population.97-99 In the absence of this system, one
can use velocity measurements from 10 consecutive cycles,
though velocities and time intervals averaged from three
nonconsecutive beats with cycle lengths within 10% to 20% of
the average heart rate are still useful.94 In addition, the variabilityof mitral inflow velocity with the RR cycle length should be examined, as patients with increased filling pressures have less beat tobeat variation.94 Examples are shown in Figures 24–27.

Key Points
1. Peak TR velocity > 2.8 m/sec is suggestive of elevated LAP.
2. In patients with depressed LVEFs, mitral DT (#160 msec) has reasonable accuracy forthe prediction of increased LV diastolic pressures and adverse clinical outcomes.
3. In patients with incomplete TR jet other Doppler measurements can be applied,
including peak acceleration rate of mitral E velocity $ 1,900 cm/sec2, IVRT #65 msec, DT of pulmonary venous diastolic velocity # 220 msec, E/Vp ratio $ 1.4,
and E/e0 ratio $ 11.
4. The variability of mitral inflow velocity with the RR cycle length is of value in patientswith AF, as patients with increased filling pressures have less beat to beat variation.

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Table 6 Assessment of LV filling pressures in special populations
Disease

Echocardiographic measurements and cutoff values

AF43,94-99

Peak acceleration rate of mitral E velocity ($1,900 cm/sec2)
IVRT (#65 msec)
DT of pulmonary venous diastolic velocity (#220 msec)
E/Vp ratio ($1.4)
Septal E/e0 ratio ($11)

Sinus tachycardia41,44

Mitral inflow pattern with predominant early LV filling in patients with EFs <50%
IVRT #70 msec is specific (79%)
Pulmonary vein systolic filling fraction #40% is specific (88%)
Average E/e0 >14 (this cutoff has highest specificity but low sensitivity)
When E and A velocities are partially or completely fused, the presence of a compensatory period after prematurebeats often leads to separation of E and A velocities which can be used for assessment of diastolic function

HCM100-106

Average E/e0 (>14)
Ar-A ($30 msec)
TR peak velocity (>2.8 m/sec)
LA volume (>34 mL/m2).

Restrictive
cardiomyopathy13,107-109

DT (<140 msec)
Mitral E/A (>2.5)
IVRT (<50 msec has high specificity)
Average E/e0 (>14)

Noncardiac pulmonary
hypertension32

Lateral E/e0 can be applied to determine whether a cardiac etiology is the underlying reason for the increased
pulmonary artery pressures
When cardiac etiology is present, lateral E/e0 is >13, whereas in patients with pulmonary hypertension due to anoncardiac etiology, lateral E/e0 is <8

Mitral stenosis110

IVRT (<60 msec has high specificity)
IVRT/TE-e0 (<4.2)
Mitral A velocity (>1.5 m/sec)

MR110-112

Ar-A ($30 msec)
IVRT (<60 msec has high specificity)
IVRT/TE-e0 (<5.6) may be applied for the prediction of LV filling pressures in patients with MR and normal EFs
Average E/e0 (>14) may be considered only in patients with depressed EFs

A comprehensive approach is recommended in all of the above settings, which includes estimation of PASP using peak velocity of TR jet (>2.8 m/sec) and LA maximum volume index (>34 mL/m2). Conclusions should not be based on single measurements. Specificity comments refer to predicting filling pressures > 15 mm Hg. Note that the role of LA maximum volume index to draw inferences on LAP is limited in athletes, patients withAF, and/or those with mitral valve disease.

F. Atrioventricular Block and Pacing
In the normal heart, sinus node depolarization spreads throughthe right and LA myocytes, arriving at the atrioventricular (AV)node within 200 msec. A properly timed atrial contraction can
increase cardiac output by 25% to 30%. Electrical activation
then travels roughly twice as fast through the specialized cardiac
conduction system, proceeding down the His-Purkinje system
and right and left bundles, which activate both ventricles simultaneously starting at the endocardium and spreading to theepicardium; with electrical repolarization taking place from
epicardium to endocardium. Normal subjects have near simultaneous contraction and relaxation of all ventricular segments,
which is demonstrated as a synchronous systolic inward and outward diastolic movement of both ventricles. Abnormities of the
cardiac conduction system due to disease, aging, drugs, or pacing
can adversely affect AV synchrony and synchronous LV contraction and relaxation, which may reduce functional aerobic capacity by altering LV systolic and diastolic function, and thus thediastolic variables used to assess diastolic function. If the PR interval is too short, atrial filling is terminated early by ventricular
contraction thus reducing mitral A duration, LV end-diastolic vol-ume, and cardiac output. A first-degree AV block of 200 to
280 msec is usually well tolerated if the LVEF and heart rate
are normal. However, in patients with shortened diastolic
filling periods due to markedly impaired LV relaxation, fasterheart rates, bundle branch block or ventricular pacing, a firstdegree AV block of >280 msec usually results in ‘‘fusion’’ of E
and A velocities (Figure 27). If atrial contraction occurs before
early diastolic mitral flow velocity has decreased to #20 cm/
sec, the E/A velocity ratio is reduced because of a higher Awave velocity.152 This ‘‘fusion’’ of early and late diastolic fillingwith an E/A velocity ratio of <1 can be misinterpreted as
impaired relaxation filling pattern (Figure 28). In addition withmitral E and A fusion, the larger atrial stroke volume increases
the mitral A-wave duration and pulmonary venous peak systolicvelocity and time-velocity integral. Diastolic fusion of fillingwaves can also limit exercise capacity because LV end-diastolicvolume is reduced, lowering maximal cardiac output. At PR
values > 320 msec, AV synchrony becomes ‘‘unphysiologic’’
because of marked E- and A-wave fusion, or filling only withatrial contraction (uniphasic A wave), and diastolic MR isseen.153 In these patients maximal exercise capacity is almostNagueh et al 297

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Figure 18 (A) Two-dimensional imaging of a patient with HCM (left top) in the parasternal long-axis view sowing systolic anteriormotion of the mitral valve (arrow). Mitral inflow shows an E/A ratio > 1 (right top). Septal (bottom left) and lateral (bottom right)
tissue Doppler early (e0 ) and late (a0 ) diastolic velocities are markedly reduced consistent with severely impaired LV relaxation.
Average E/e0 ratio is >14, consistent with elevated mean LAP. Abbreviations as in other figures. (B) Peak TR velocity (3.42 m/sec) by CW Doppler from the same patient in (A). Peak RV–to–right atrial systolic pressure gradient is 47 mm Hg. Thus, PASP is$47 mm Hg.

always limited because of the inability to increase LV fillingwith increasing heart rate. If only the mitral A wave is present,
only TR velocity can be used as a possible indicator of LV fillingpressures.

A right bundle branch block results in delayed activation of the
RV myocardium as electrical depolarization must spread throughmyocytes instead of the specialized conduction system. Althoughminor changes in LV and RV synchrony are observed no studies

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Figure 19 Algorithm comparing constrictive pericarditis and restrictive cardiomyopathy. Note restriction is associated with elevated
E/A ratio, short DT and decreased mitral annular velocity (<6 cm/sec). The figure is based on data from Welch TD, Ling LH, Espinosa
RE, et al. Echocardiographic diagnosis of constrictive pericarditis: Mayo Clinic criteria. Circ Cardiovasc Imaging 2014;7:526–34.
have convincingly shown that this leads to clinically meaningfulchanges in LV diastolic variables or exercise capacity. This isalso true of left anterior or right posterior hemiblock. In contrast,
left bundle branch block is frequently associated with organic
heart disease and impaired LV diastolic function. As with otherdisease states with impaired relaxation, the effect on mitralfilling variables is heavily influenced by LV stiffness and loading
conditions. With normal LAP, an impaired LV relaxation filling
pattern is seen, while pseudonormal and restrictive patterns
occur with progressive increases in LV stiffness and LAP. As
long as no fusion of mitral E and A velocities occurs, the variables
used to evaluate diastolic function and filling pressures likely
remain valid.
The effect of cardiac pacing on LV systolic and diastolic function varies by patient group. Chronic RV pacing is known to bedeleterious by inducing LV dyssynchrony, leading to a reduction
in LV ejection fraction, stroke volume, impaired LV filling and anincreased incidence of heart failure and AF.154 Patients who
mostly need atrial pacing with rare RV pacing are believed tohave no alterations in systolic and diastolic function. In patientswith AV delay, pacemaker settings are often set with a long AV
delay to encourage fusion or native QRS beats to minimize RV
pacing. When this requires an excessively long PR interval, E
and A velocities fuse and diastolic MR may be seen. As discussed
previously, the alteration in E and A velocities and pulmonary

venous flow variables limits their clinical application for diastolic
function assessment in this setting. There are few studies thathave looked at the utility of mitral annular velocities in this setting
and it appears that their accuracy is less in the presence of left
bundle branch block, RV pacing, and in patients who havereceived cardiac resynchronization therapy.67,155

Key Points
1. In patients with first degree AV block, the variables used to evaluate diastolic function
and filling pressures likely remain valid as long as there is no fusion of mitral E and A
velocities.
2. The accuracy of mitral annular velocities and E/e0 ratio is less in the presence of left
bundle branch block, RV pacing, and in patients who have received cardiac resynchronization therapy.
3. If only mitral A velocity is present, only TR peak velocity (>2.8 m/sec) can be used as
an indicator of LV filling pressures.

VI. DIASTOLIC STRESS TEST
Exercise echocardiography156 is usually performed to detect
reduced LV systolic and/or diastolic reserve capacity in the settingof coronary disease or diastolic dysfunction, as patients with diastolic
dysfunction may have a similar hemodynamic profile (in terms ofcardiac output and filling pressure) at rest as healthy individuals
who have normal diastolic function. When normal subjects exercise,Nagueh et al 299

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Figure 20 Restrictive physiology in advanced cardiac amyloidosis showing (left upper) elevated E/A ratio and short DT,
decreased mitral annular septal velocities (left lower) and lateral velocities (right lower) and apical sparing on deformation imaging (right upper).

they are able to increase stroke volume without significantly
increasing filling pressures because of augmented myocardial relaxation along with more powerful early diastolic suction. Reduced LV
relaxation is one of the earliest manifestations of myocardial
dysfunction. Myocardial relaxation is consistently reduced in all
forms of myocardial disease, including hypertensive heart disease,
myocardial ischemia and HCM.157 More important, patients withdiastolic dysfunction may not be able to augment myocardial relaxation with exercise compared with normal subjects (Figure 29).
Hence, these patients can only achieve the required cardiac output
at the expense of increased LV filling pressures. In normal subjects,
mitral early diastolic E velocity increases with the augmented LV
suction. Mitral annular e0 velocity likewise increases proportionallywith E velocity with exercise so that E/e0 ratio remains unchanged
from resting state to exercise.158 Normal E/e0 values have been published for middle-age and younger age subjects using treadmill andbicycle exercise with remarkably similar values of 6 to 8 at rest andwith exercise.159,160 Previous studies showed exercise diastolic
parameters correlate better with exercise capacity than resting
parameters. Overall, the faster the myocardial relaxation (e0 ) is,
the higher the exercise capacity. Since augmentation of
myocardial relaxation as reflected in e0 velocity is limited inpatients with diastolic dysfunction, the E/e0 ratio increases with
exercise. Several studies have shown a good correlation between
E/e0 ratio and invasively obtained pulmonary capillary pressure,
LAP or LV mean diastolic pressure with variable levels of effort,
including day-to-day activity as well as supine bike exercise in thecatheterization laboratory.161-163

A. Indications
Diastolic stress testing is indicated when resting echocardiography does not explain the symptoms of heart failure or dyspnea,
especially with exertion. In general, patients with completely
normal hearts and diastolic function at rest with preserved e0 velocity (>7 cm/sec for septal e0 , >10 cm/sec for lateral e0 ) need
not undergo stress testing as it is highly unlikely that they willdevelop diastolic dysfunction and elevated filling pressureswith exercise. Likewise, patients with abnormal findings atbaseline consistent with elevated LV filling pressures should
not be referred for stress testing as the cardiac etiology for dyspnea has already been established and their filling pressures
will almost certainly increase further with exercise. The mostappropriate patient population for diastolic exercise testing is
the group of patients with grade 1 diastolic dysfunction, whichindicates delayed myocardial relaxation and normal LA meanpressure at rest.
B. Performance
Diastolic stress testing is best performed with exercise and not using
dobutamine as the administration of the drug does not simulate the
day-to-day physiologic stress. It is easier to perform the test using supine bike protocol which allows ample time to acquire 2D and
Doppler data. During the supine bicycle test, 2D images, mitral
inflow velocities, mitral annulus tissue Doppler velocities, andpeak TR velocity by CW Doppler are acquired at baseline, during
each stage including peak exercise and in recovery. In addition,

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Figure 21 Patient with mitral stenosis and LV diastolic dysfunction. (A) Color Doppler flow across stenotic mitral valve
showing flow acceleration zone (left) and CW Doppler (right) of forward diastolic mitral inflow showing increased peakvelocity (1.5 m/sec) and gradient (peak gradient = 8 mm Hg and mean gradient = 3.4 mm Hg) across the stenotic mitralvalve. (B) TR jet by CW Doppler (left) showing RV–to–right atrial pressure gradient of 49 mm Hg. Hepatic venous flow(right) shows forward flow only in diastole (D) consistent with increased right atrial pressure. Together, there is evidence ofpulmonary hypertension.

diastolic stress testing can be part of exercise treadmill testing anddata are acquired at baseline and in early recovery. Of note, mitral
inflow and annular early and late diastolic velocities are frequently
fused at peak exercise. This is particularly true during treadmill tests
wherein patients usually achieve higher heart rates than thosereached during supine bike testing. Nevertheless, it is possible to acquire Doppler signals later during recovery when the heart rate isslower and merging is less of a problem. This applies to both modalities of stress testing.

When the indications for stress testing are chest pain anddyspnea, including patients with known or suspected coronary
artery disease, it is important to prioritize the collection of 2D
images for wall motion analysis. If echocardiographic contrast
is used for LV cavity opacification, tissue Doppler signals are
not useful and only TR velocity can be of value. The provider
can consider two separate tests in this setting. Whether
contrast is used or not, one should proceed immediately after
treadmill exercise is terminated to acquire 2D images so as toNagueh et al 301

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D. Detection of Early Myocardial Disease and Prognosis
There is a paucity of data on the prognostic utility of diastolic
stress testing. It has been demonstrated that increased LV fillingpressure (E/e0 > 13) with exercise has an incremental prognostic
power to clinical parameters as well as 2D findings diagnostic of
myocardial ischemia.164 Regarding detection of subclinical disease, the increment in systolic and diastolic longitudinal velocitiesof the mitral annulus is generally reduced in patients withmyocardial disease as in patients with diabetes mellitus
compared with control subjects165 and exercise induced diastolic
dysfunction appears promising in identifying these patients fortargeted treatment. Although the use of dobutamine for diastolic
stress testing is discouraged, one report noted that the presenceof a persistent restrictive LV filling pattern with dobutamine
was associated with poor long-term outcomes in patients withischemic cardiomyopathy.166

Key Points

Figure 21 (continued). (C) Mitral inflow (top) and septal mitralannulus tissue Doppler velocities (bottom). Notice the delayed
e0 velocity such that mitral E begins before annular e0 velocity(TE-e0 = 49 msec). Abbreviations as in other figures.

ideally visualize all LV segments within 60 sec for assessmentof myocardial ischemia. Subsequently, Doppler echocardiography can be obtained when there is a separation of early andlate diastolic mitral flow and annular velocities. If merging isnoted still, one should proceed to record peak TR velocity by
CW Doppler and then reattempt recording mitral inflow andannular tissue Doppler velocities when the heart rate has
decreased further.

C. Interpretation
The successful acquisition of Doppler signals during exercise
and the interpretation of the diastolic stress test require a higher
level of experience than that needed for evaluation of diastolic
function at rest. The test is considered definitely abnormal indicating diastolic dysfunction when all of the following three
conditions are met: average E/e0 > 14 or septal E/e0 ratio > 15with exercise, peak TR velocity > 2.8 m/sec with exercise andseptal e0 velocity is < 7 cm/sec or if only lateral velocity is acquired, lateral e0 < 10 cm/sec at baseline. The results are normalwhen average (or septal) E/e0 ratio is <10 with exercise and peakTR velocity is <2.8 m/sec with exercise. One should be cautious
in drawing conclusions on the basis of an isolated increase in
exercise peak TR velocity as normal subjects can have a significant increase in peak TR velocity related to the increased pulmonary blood flow. In the absence of these results, the test is
considered indeterminate. In these patients, an invasive hemodynamic investigation, including the use of exercise, maybe neces-

1. Diastolic stress testing is indicated in patients with dyspnea and grade 1 diastolic dysfunction at rest. It is performed using supine bike or treadmill stresstesting.
2. At rest, mitral E and annular e 0 velocities should be recorded, along with thepeak velocity of TR jet from multiple windows. The same parameters are recorded during exercise or 1 to 2 min after termination of exercise when E
and A velocities are not merged, because increased filling pressures usually persist for few minutes.
4. The test is considered positive when all of the following three conditions are met during exercise: average E/e0 > 14 or septal E/e0 ratio > 15, peak TR velocity > 2.8 m/sec
and septal e0 velocity < 7 cm/sec.

VII. NOVEL INDICES OF LV DIASTOLIC FUNCTION
Several indices of LV and LA systolic and diastolic function havebeen proposed in recent years as indices of LV relaxation and LV
and LA filling pressures. In general, patients with HFpEF usually
have abnormally depressed LV GLS such that LVEDP varies
directly with LV GLS. Lower absolute value for GLS denotes
more impaired LV global longitudinal function. However, there
is wide scatter in such data so the relation cannot be used for estimation of LV filling pressures. LV global longitudinal diastolicstrain rate measurements during the isovolumic relaxation period
and during early diastole by STE have a significant association
with the time constant of LV relaxation (t). These novel parameters have been used in conjunction with mitral E velocity to estimate LV filling pressures and to predict outcomes in several
disease states.167-174 Notwithstanding the encouraging results
reported by several investigators, the technical challenges andthe variability in strain rate measurements on the basis of theultrasound system and the software used for analysis limit dayto-day application of these parameters.
LV untwisting rate175,176 is another parameter that has garneredinterest as a surrogate of LV relaxation.177,178 Both animal andhuman studies have shown that LV relaxation is not the soledeterminant of this measurement. LV filling pressures, LV recoil
and thus LV systolic function affect it as well.179-183 In fact, there
are several studies that have shown normal LV untwisting rate inpatients with HFpEF. However, the timing of peak untwistingJournal of the American Society of Echocardiography
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Figure 22 Mitral inflow (top) and septal (bottom left) and lateral (bottom right) mitral annular velocities by tissue Doppler from a patientwith heart transplantation and LV diastolic dysfunction. Notice the reduced septal and lateral e0 velocities (5–6 cm/sec). Abbreviations
as in other figures.

Figure 23 Mitral inflow (top left: pulsed-wave Doppler of mitral inflow at level of mitral annulus; top right: pulsed-wave Dopplerof mitral inflow at level of mitral valve tips) from another heart transplantation patient in a ventricular paced rhythm and withseverely depressed LV systolic function and diastolic dysfunction (bottom: markedly reduced septal e0 velocity at 2–3 cm/sec). Notice the presence of short DT of mitral E velocity (<150 msec), abbreviated diastolic flow duration with prematuretermination of forward flow. There is also diastolic MR (arrows). All of the above findings are consistent with markedly elevated
LV filling pressures, which includes LVEDP. Abbreviations as in other figures.

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Figure 24 Doppler recording from a patient with atrial flutter.
Notice the presence of flutter waves (F) and diastolic MR (arrows).

rate can be of more value in diagnosing patients with diastolic
dysfunction and normal LV volumes and EF.177,182 In the lattergroup of patients, delayed peak of LV untwisting rate is often
present as might be expected with delayed LV relaxation. Given
the complexity of the measurement and the difficulty indeciphering the contribution of each of the underlying variables
that affect it, more studies are needed to prove it has a role inthe day-to-day clinical practice.
Recently there have been a number of observational studies
demonstrating an inverse correlation between LA systolic strain
and mean wedge pressure. It appears that the relation is betterin patients with HFrEF, though significant correlations were also
noted in patients with HFpEF.184 LA systolic strain can be combined with invasive and noninvasive measurements of LAP to estimate LA stiffness, which appears to be a promising variable indistinguishing patients with HFpEF from those with diastolic
dysfunction who are not in heart failure.185 Likewise, assessmentof LA conduit function appears promising.186 Although promising, there are technical challenges for accurate LA strain measurements in patients with marked LA enlargement and LA
areas with echo dropout.

Key Points
1. LV global longitudinal diastolic strain rate measurements during the isovolumic
relaxation period and during early diastole by STE have a significant association
with the time constant of LV relaxation (t). These parameters have been used inconjunction with mitral E velocity to estimate LV filling pressures and to predict
outcome in several disease states.
2. The timing of peak untwisting rate can be of value in diagnosing patients with diastolic dysfunction and normal LV volumes and EF. In the latter group of patients, delayed peak of LV untwisting rate is often present.
3. An inverse correlation is present between LA systolic strain and mean wedge
pressure. Although promising, there are technical limitations, and experienceis essential.

VIII. DIASTOLIC DOPPLER AND 2D IMAGING VARIABLES
FOR PROGNOSIS IN PATIENTS WITH HFREF
Diastolic dysfunction with impaired LV relaxation develops earlyin most cardiac diseases and can progress to include increased
LV stiffness which leads to the elevation of LV filling pressures.

Echocardiographic measurements of diastolic function reflecttissue changes and therefore provide important prognostic information. Clinical studies have shown the association of shortmitral DT (indicating increased LV chamber stiffness) with heart
failure symptoms, death and hospitalization in patients presenting
with acute myocardial infarction and those with HFrEF. In thispopulation, DT provided incremental prognostic information toclinical parameters, wall motion score index and LVEF.73-86,88-91
Importantly, a meta-analysis of 12 post–acute myocardial infarction studies involving 1,286 patients confirmed the prognostic
power of restrictive diastolic filling in patients with LV dysfunction,86 as did an echocardiographic substudy of 620 patientswith acute myocardial infarction from the OASIS-6 study.187
In addition, the less abnormal pseudonormal filling pattern
has also been shown to portend poor outcomes in patientswith heart failure, which was similar to that seen with restrictive
LV filling in some studies.188 Pulmonary venous velocities189-191
and Vp30,192-194 were less frequently examined but were still
predictive of clinical events. Given the variability in measuring
DT, Vp, and pulmonary venous flow velocity duration, more
recent studies have examined the prognostic power of E/e0
ratio. Several studies have shown that e0 velocity and E/e0
ratio are highly predictive of adverse events after acute
myocardial infarction and in patients with and without heart
failure.102,132,194-204 A recent study has shown that low valuesof both global tissue Doppler–derived mitral annular s0 and e0
velocities were independent predictors of higher risk for deathin patients after myocardial infarction.205 Doppler-estimated
PASP has also been shown to be a robust predictor of outcome
in heart failure patients.206,207 Likewise, increased LA and rightatrial volume indices have been shown to portend an adverse
prognosis in patients with myocardial infarction and heart
failure.208-211
More recently, novel echocardiographic indices (longitudinal andcircumferential strain and diastolic strain rate by STE) have beenshown to predict outcomes in patients after myocardial infarction,and in patients with systolic heart failure, above and beyond LVEF
and E/e0 ratio.172-174,212-216 Similarly, LA strain, a measure of LA
deformation related to LAP, has also been shown to portend an
adverse prognosis in patients with myocardial infarction that isincremental to LA maximum volume index.217,218

Key Points
1. Mitral inflow velocities and pulmonary vein velocities and time intervals provide
important prognostic data in patients with LV systolic dysfunction that is incremental to clinical and LV volumetric variables.
2. Mitral annular velocities, including E/e0 ratio, have likewise been reported to predict
outcomes in these patient groups.
3. Grade II or grade III diastolic dysfunction that does not improve despite adequate
medical therapy are highly predictive of worse outcomes in this patient population.
4. There is growing literature showing LV strain and diastolic strain rate signals as well as
LA strain providing incremental prognostic information in several disease states,
including patients presenting with acute myocardial infarction, AF and HFrEF.

IX. PREDICTION OF OUTCOMES IN PATIENTS WITH HFPEF
In patients with HFpEF, the prognostic relevance of diastolic
dysfunction has been evaluated in a framework, including clinical,
laboratory and echocardiographic indicators of prognosis andoutcome. For clinical and laboratory variables, the most powerfulJournal of the American Society of Echocardiography
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Figure 25 Doppler recordings from a patient with AF and elevated LV filling pressures. Mitral inflow (top left) shows increased peakdiastolic velocity (E) at 90 to 100 cm/sec and increased acceleration rate. L velocity is seen in the mitral inflow signal (arrow). TR peakvelocity (top right) is y 3.2 m/sec, corresponding to RV–to–right atrial pressure gradient of 42 mm Hg and thus increased PASP.
Septal (bottom left) and lateral (bottom right) annular diastolic velocities are markedly reduced with an average E/e0 ratio y 30. Collectively, the above findings are consistent with increased LV filling pressures.

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Figure 26 Doppler recordings from a patient with increased LV filling pressures. Notice the increased peak velocity and acceleration
rate of the diastolic forward flow signal (left). IVRT is short at 50 ms (right). Arrows point to diastolic MR which is consistent withincreased LVEDP.

Figure 27 Mitral inflow in a patient with a first-degree AV block.
Notice merging of mitral E and A velocities and the shortened diastolic filling period. Mitral A velocity ends before end-diastole (arrow) and leads to an abbreviated diastolic filling period.

prognostic parameters were N-terminal pro–B-type natriuretic
peptide, age, diabetes mellitus and previous hospitalization forheart failure in the I-PRESERVE study. Other independent factors
associated with poor outcome were quality of life, chronic
obstructive lung disease, neutrophil count, heart rate and estimated glomerular filtration rate.219 Similarly, in the KarolinskaRennes (KAREN) study, the independent predictors of prognosis
were age, history of noncardiovascular syncope (a proxy forfrailty), valvular heart disease, anemia, lower sodium, and higher
potassium levels (impaired renal function). Of note, the use ofrenin–angiotensin system antagonists and mineralocorticoid receptor antagonists independently predicted improved prognosis.220 Other studies looked at the value of specificparameters such as worsening of renal function (I-PRESERVE
data), albuminuria independently from renal function, andanemia.221-223

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Figure 28 Effect of heart rate on merging of E and A velocities and need to consider mitral velocity at onset of A. Left panel
recording was obtained at heart rate of 82/min with mitral velocity at onset of A exceeding 20 cm/sec (arrow), which if not considered (subtracted from peak A velocity) results in the erroneous conclusion of impaired relaxation pattern. Right panel was obtained
from the same patient at heart rate of 65 beats/min in whom mitral velocity at onset of A is < 20 cm/sec. The right panel shows thatthe patient indeed has pseudonormal LV filling.

Figure 29 Mitral septal annulus (left), mitral inflow (middle), and TR velocity (right) at rest (top) and immediately after treadmill
exercise test (bottom). It shows E/e0 of 10 and normal PASP at rest. With exercise, e0 remains the same and E
velocity increased such that E/e0 ratio increased to 19 along with an increase of PASP to $49 mm Hg with TR velocity of
3.5 m/sec.
For echocardiographic parameters, RV dysfunction was present
in a significant subset of patients with HFpEF from Olmsted
County, Minnesota, and was associated with worse outcomes.
Importantly, RV dysfunction provided important prognostic information, which was independent from the prognostic informationof PASP.224 In the I-PRESERVE echocardiographic substudy, LV
mass and LA size remained independently associated with anincreased risk of morbidity and mortality.225 In the TOPCAT
echocardiographic substudy, neither LV volumes nor EF was pre-dictive of worse outcomes. However, LV hypertrophy, septal E/e0
ratio, and TR peak velocity were predictive of outcome beyond
clinical and laboratory characteristics. Because LV hypertrophy,
elevated filling pressures, and elevated PASP frequently coexist,
a greater number of these abnormalities is associated with ahigher risk for incident hospitalization for heart failure226 as is
the presence of a reduced GLS.227 Another potentially usefulparameter is the pulmonary vein S/D ratio, which proved tohave an added prognostic significance in an observational

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Figure 30 A forward and a backward-traveling (reflected) wave contribute to pressure changes in the central aorta. In theyoung and healthy subject on the left, the backward-traveling wave arrives at end-systole, contributes to closing the aortic
valve and to increasing diastolic perfusion pressure. In the hypertensive subject on the right, the backward-traveling wave
reaches the proximal aorta in early systole and contributes to the late systolic peak in pressure. The magnitude of the reflected wave (and the late systolic pressure) has a well-validated and independent prognostic significance as summarized
in the guidelines.

study,228 likely related to the dynamics of systolic pulmonary
venous flow, which are determined by mechanisms that are
different from those that affect diastolic venous flow velocities.229
These observations have triggered interest in further study of existing and novel echocardiographic parameters.230
Arterial function with its resistive and pulsatile aspects may
further refine the prognostic evaluation of patients with HFpEF.
In general, the best validated parameter is pulse-wave velocity.231
An emerging parameter is pathologic wave reflection in thearterial tree (Figure 30), and hence late systolic wall stress.232
The magnitude of wave reflection appears to be independently
associated with diastolic dysfunction233-235 and increased LV
mass.236 It is an independent predictor of cardiovascular events,
specifically incident heart failure237 and mortality.238 The prognostic value of wave reflection is independent of and as potent
as systolic blood pressure. Late systolic wall stress is associatedwith population characteristics opposite to those seen withearly systolic wall stress. This provides an original, novel clue todistinct hemodynamic triggers of physiologic and pathologic hypertrophy including diastolic dysfunction. Of note, early systolicload triggers physiologic adaptations, while late systolic load induces maladaptive cardiac changes that are associated withadverse outcomes.

of Directors, the EACVI Scientific Documents Committee, andexternal reviewers.
ASE reviewers included Deborah A. Agler, RCT, RDCS, FASE,
Federico M. Asch, MD, FASE, Gerard P. Aurigemma, MD, FASE,
Merri L. Bremer, EdD, RN, EDCS, ACS, FASE, Hollie D. Carron,
RDCS, FASE, Frederick C. Cobey, MD, FASE, Meryl S. Cohen,
MD, FASE, Patrick Collier, MD, PhD, FASE, Mary C. Corretti,
MD, FASE, Benjamin W. Eidem, MD, FASE, Fadia Makarem
Ezzeddine, RT, RCS, FASE, Neal Gerstein, MD, FASE, Yvonne E.
Gilliland, MD, FASE, Aasha S. Gopal, MD, FASE, Stephen
Heitner, MD, FASE, Thomas V. Johnson, MD, FASE, Joe R.
Kreeger, ACS, RCCS, RDCS, FASE, Stamatios Lerakis, MD,
FASE, Sunil Mankad, MD, FASE, Rick Meece, ACS, RDCS,
RCIS, FASE, Patricia M. Restrepo, Vera H. Rigolin, MD, FASE,
Brad J. Roberts, ACS, RCS, FASE, Anita Sadeghpour, MD, FASE,
Fadi Shamoun, MD, FASE, Roman M. Sniecinski, MD, FASE,
Vincent L. Sorrell, MD, FASE, Cynthia Taub, MD, FASE, Steven
Walling, RCS, RDCS, FASE, Neil J. Weissman, MD, FASE, andSusan E. Wiegers, MD, FASE.
EACVI reviewers included Nuno Cardim, MD, PhD, Bernard
Cosyns, MD, PhD, Victoria Delgado, MD, PhD, Erwan Donal, MD,
PhD, Maurizio Galderisi, MD, PhD, Gilbert Habib, MD, PhD,
Kristina H. Haugaa, MC, PhD, Philipp Kauffmann, MD, PhD, Denisa
Muraru, MD, Walter J. Paulus, MD, PhD, Sven Plein, MD, PhD.

Key Points
1. Echocardiographic data adds incremental prognostic information in patients with
HFpEF. They include LV hypertrophy, LA volumes, E/e0 ratio, peak velocity of TR
jet, RV function, and GLS.
2. Arterial function with its resistive and pulsatile aspects further refines the prognostic
evaluation of patients with HFpEF.

REVIEWERS
This document was reviewed by members of the 2015–2016 ASE
Guidelines and Standards Committee, the 2015–2016 ASE Board

NOTICE AND DISCLAIMER
This report is made available by the ASE and the EACVI as acourtesy reference source for members. This report contains recommendations only and should not be used as the sole basis tomake medical practice decisions or for disciplinary action against
any employee. The statements and recommendations containedin this report are based primarily on the opinions of experts,
rather than on scientifically-verified data. The ASE and theEACVI make no express or implied warranties regarding theJournal of the American Society of Echocardiography
Volume 29 Number 4completeness or accuracy of the information in this report,
including the warranty of merchantability or fitness for a particular purpose. In no event shall the ASE or the EACVI be liable
to you, your patients, or any other third parties for any decision
made or action taken by you or such other parties in relianceon this information. Nor does your use of this information constitute the offering of medical advice by the ASE and the EACVI or
create any physician-patient relationship between the ASE and/or
the EACVI and your patients or anyone else.

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