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4.5 A Simple Approach to Diastolic Dysfunction

From what you have read so far, the assessment of diastolic dysfunction might appear difficult. In fact, all of the described methods have their limitations. Aligning this information might seem complex. However, you will rarely need to perform more than one or two of the above-mentioned methods. In clinical practice, all you need is a crude estimate of diastolic dysfunction and filling pressures. The latest update of the guidelines has already aimed to simplify the process and you can now rely upon four criteria to make decision making easier.

4.5.1 Grading of Diastolic Dysfunction:

Ask yourself the following questions to determine whether diastolic dysfunction is present and how severe it is

Question 1: Does my patient have a normal LVEF (>= 50%)?

If yes, your goal should be to assess whether there is diastolic dysfunction present or not - but there is no need to further grade it.
In this case answer questions 2-5: if you answer more than 50%  with “Yes” there is diastolic dysfunction present. If you answer exactly half of them with “Yes” the diastolic function cannot be determined.

If no, your goal should be to grade the severity of diastolic dysfunction and estimate left atrial pressure (LAP). In this case, you need to take a look at the E/A-ratio and peak E wave velocity.

If E/A is < 0.8 and E < 50 cm/s the patient has grade I diastolic dysfunction and normal LAP.

If E/A is > 2 the patient has grade III diastolic function and increased LAP.

If E/A is >0.8 and < 2 or E > 50 cm/s, ask yourself Questions 3-5 to differentiate between grade I, grade II and Indeterminate diastolic function.

If you answer more than 50% with “Yes” the patient has grade II diastolic dysfunction with increased LAP.

If you answer exactly 50% with “Yes”, the diastolic function and LAP cannot be determined.

If you answer less than 50% with “Yes”, the patient has grade I diastolic dysfunction and normal LAP.

Question 2: Does my patient have a reduced septal e’ < 7 cm/s or a lateral e’ < 10 cm/s?

Question 3: Does my patient have an increased average E/e’ > 14?

Question 4: Does my patient have an enlarged left atrium with an LA volume index >34 ml/m²?

Question 5: Does my patient have an increased sPAP represented by a peak TR velocity > 2,8 m/s?

Depending on whether a TR is present or not, it is possible to have one criterium less to evaluate. Alternatively, you can ask yourself: Is the pulmonary S/D ratio < 1?

Here are is a flowchart of the algorithm for assessing diastolic function for both, normal and reduced LVEF as recommended by the current guidelines.

normal-LV-EF
Nagueh et al. (J. Am. Soc. Echocardiogr. 2016)
mitral-inflow
Nagueh et al. (J. Am. Soc. Echocardiogr. 2016)

Find full guidelines here: Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging (PDF), Nagueh et al. (J. Am. Soc. Echocardiogr. 2016).