LV Diastolic Function Grading: 2025 ASE Algorithm
Thresholds, algorithms and interpretation from the 2025 ASE update — diagnosis of diastolic dysfunction, left atrial pressure estimation, dedicated pathways for AF, MAC, pulmonary hypertension and transplant recipients, measurement pitfalls and reporting.
The interactive tool below applies the correct 2025 ASE pathway once you select the clinical context. The full reference — diagnostic criteria, threshold tables, phenotype algorithms, pitfalls and reporting guidance — follows underneath.
Interactive Diastolic Function Grading Tool
Select the clinical context and enter measurements step by step. The tool applies the correct 2025 ASE algorithm and shows the variables that drove the result. Use the Back button to revise any step.
Result
Two Separate Questions: Is Diastolic Dysfunction Present, and Is LAP Elevated?
The 2025 ASE update separates two questions that are frequently conflated. The first — is LV diastolic dysfunction present? — follows Figure 2 and uses age-specific e′ cut-offs. The second — is mean left atrial pressure elevated, and what grade? — follows Figure 3 and uses age-independent e′ cut-offs. Applying the wrong set of cut-offs to the wrong question is the most common source of error in diastolic reporting.
Step 1 — Assess LV Relaxation (Age-Specific Cut-offs)
These are diagnostic cut-offs for impaired relaxation, not population reference ranges. An e′ below the value for the patient's age group counts as reduced.
| Age | Abnormal septal e′ | Abnormal lateral e′ | Abnormal average e′ |
|---|---|---|---|
| 20 – 39 years | < 7 cm/s | < 10 cm/s | < 9 cm/s |
| 40 – 65 years | < 6 cm/s | < 8 cm/s | < 7 cm/s |
| > 65 years | < 6 cm/s | < 7 cm/s | < 6.5 cm/s |
Step 2 — Markers of Elevated LAP and Structural Remodelling
| Parameter | Abnormal | Role |
|---|---|---|
| Average E/e′ | > 14 | Elevated LAP marker |
| LA reservoir strain (LARS) | ≤ 18% | Elevated LAP marker |
| E/A ratio (high) | ≥ 2 | Elevated LAP marker |
| E/A ratio (low) | ≤ 0.8 | Impaired relaxation — not elevated LAP |
| LA volume index (biplane) | > 34 mL/m² | Structural surrogate |
| LV mass index — men | > 115 g/m² | Structural surrogate |
| LV mass index — women | > 95 g/m² | Structural surrogate |
Primary Variables — Sinus Rhythm LAP Algorithm
Three primary variables are assessed simultaneously. These cut-offs are age-independent and belong to the filling-pressure algorithm, not the diagnostic step above. For LA size and strain reference values, see left atrial size and function.
| Variable | Abnormal threshold |
|---|---|
| 1. Reduced e′ velocity | Septal e′ ≤ 6 cm/s, lateral e′ ≤ 7 cm/s, or average e′ ≤ 6.5 cm/s |
| 2. Increased E/e′ ratio | Septal E/e′ ≥ 15, lateral E/e′ ≥ 13, or average E/e′ ≥ 14 |
| 3. Increased TR velocity / PASP | TR velocity ≥ 2.8 m/s or PASP ≥ 35 mmHg |
Supplementary Criteria
| Primary supplementary | Threshold |
|---|---|
| Pulmonary vein S/D ratio | ≤ 0.67 |
| LA reservoir strain (LARS) | ≤ 18% |
| LA volume index (LAVi) | > 34 mL/m² |
| IVRT | ≤ 70 ms |
| Additional supplementary methods | Threshold |
|---|---|
| PR end-diastolic velocity | ≥ 2 m/s |
| PA diastolic pressure | ≥ 16 mmHg |
| Mitral inflow L-wave velocity | ≥ 50 cm/s |
| Ar–A duration | > 30 ms |
| Decrease in mitral E/A with Valsalva | ≥ 50% |
Diastolic Dysfunction Grades
| Grade | Filling pattern | E/A | Mean LAP | Interpretation |
|---|---|---|---|---|
| Normal | Normal relaxation | E > A (young), E ≈ A (older) | Normal | Normal diastolic function with no elevation of filling pressures. |
| Grade 1 | Impaired relaxation | ≤ 0.8 | Normal | Impaired relaxation with normal estimated mean LAP at rest. LVEDP may still be elevated. In symptomatic patients, a normal resting pressure does not exclude exercise-induced elevation — consider diastolic exercise echocardiography. |
| Grade 2 | Pseudonormal | 0.8 – 2.0 | Elevated (mild–moderate) | Inflow appears normal but filling pressures are elevated. Supplementary variables are needed to unmask it. A Valsalva-induced fall in E/A of ≥ 50% distinguishes Grade 2 from Grade 1. |
| Grade 3 | Restrictive | ≥ 2.0 | Elevated (marked) | Markedly elevated filling pressures with a stiff, non-compliant ventricle, short deceleration time and adverse prognosis. |
When Resting Echo Is Not Enough
A normal resting study does not exclude exercise-induced elevation of filling pressure. Diastolic stress echocardiography should be considered in four situations:
| Situation | Why |
|---|---|
| Exertional dyspnoea with Grade 1 dysfunction | Resting LAP is normal by definition in Grade 1, so the resting study cannot address the symptom |
| Indeterminate resting LAP | Exercise frequently resolves the ambiguity |
| High clinical suspicion of HFpEF despite a normal resting study | Filling pressure may only rise with tachycardia and increased venous return |
| Isolated elevation of LVEDP | Predisposes to elevated mean LAP with exercise or tachycardia |
Phenotype-Based Approach — When to Deviate from the Standard Algorithm
The standard diastolic variables break down when the underlying physiology is altered — absent atrial contraction, a rigid annulus, surgically modified chambers, or right ventricular pressure loading. The guideline assigns dedicated algorithms to each phenotype, selecting the variables that remain physiologically valid. The core principle: identify which component of the assessment is unreliable, then shift to the parameter that still works.
| Phenotype | What breaks | Most reliable parameters | Unreliable / avoid |
|---|---|---|---|
| Sinus rhythm | Nothing — normal physiology | e′, E/e′, E/A, LAVi, LA strain | — |
| Atrial fibrillation | No atrial contraction; irregular RR intervals | E velocity and E/e′ averaged over ≥ 5 beats, TR velocity, DT | E/A ratio; single-beat measures; LARS as a standalone marker; PV Ar velocity (absent) |
| Moderate–severe MAC | Rigid annulus lowers e′ while a reduced orifice raises E | E/A, then IVRT when intermediate | e′ and E/e′ — artificially elevated |
| Heart transplant | Denervation, small stiff surgical LA, altered filling physiology | Average E/e′ with strict cut-offs, E/SRIVR, TR velocity | E/A pattern; PV S/D ratio |
| Pulmonary hypertension | RV pressure loading and septal displacement | E/A with E velocity qualifier, then LARS or lateral E/e′ | Septal e′ and average E/e′; TR velocity as a primary variable |
| LBBB / RV pacing | Septal dyssynchrony reduces septal e′ | Lateral E/e′, TR velocity, LA volume and strain | Septal and average E/e′ |
Atrial Fibrillation
Average all measurements over at least five cycles, selecting beats that reflect the average heart rate. No single parameter is sufficient.
| Primary variable | Abnormal |
|---|---|
| Mitral E velocity | ≥ 100 cm/s |
| Septal E/e′ | > 11 |
| TR velocity / PASP | > 2.8 m/s or > 35 mmHg |
| Deceleration time | ≤ 160 ms |
| ≥ 3 abnormal → elevated LAP · ≤ 1 abnormal → normal LAP · 2 abnormal → apply secondary criteria | |
| Secondary criteria (when exactly 2 primary are abnormal) | LARS < 18%, PV S/D < 1, BMI > 30 kg/m² — ≥ 2 present → elevated LAP; none → normal LAP; 1 or unavailable → indeterminate |
Moderate–Severe Mitral Annular Calcification
This pathway applies specifically to moderate or severe MAC, not to mitral valve disease generally. Significant MAC reduces the effective mitral orifice, raising transmitral velocities, while restricting annular excursion and lowering lateral e′ — inflating E/e′ from both directions.
| Finding | Conclusion |
|---|---|
| E/A < 0.8 | Normal LAP |
| E/A > 1.8 | Elevated LAP |
| E/A 0.8 – 1.8, IVRT < 80 ms | Elevated LAP |
| E/A 0.8 – 1.8, IVRT ≥ 80 ms | Normal LAP |
Mitral Stenosis and Mitral Regurgitation
Mitral stenosis and mitral regurgitation have their own indicators and should not be assessed with the MAC pathway.
| Lesion | Indicators of elevated LAP |
|---|---|
| Mitral stenosis | IVRT < 60 ms; mitral A peak velocity > 1.5 m/s; IVRT/TE-e′ < 4.2 |
| Mitral regurgitation | IVRT < 60 ms; Ar–A duration ≥ 30 ms; IVRT/TE-e′ < 5.6 |
Heart Transplant Recipients
| Finding | Conclusion |
|---|---|
| Average E/e′ < 7 | Normal LAP |
| Average E/e′ > 14 | Elevated LAP |
| Average E/e′ 7 – 14, E/SRIVR ≤ 200 cm | Normal LAP |
| Average E/e′ 7 – 14, E/SRIVR > 200 cm | Elevated LAP |
| E/SRIVR unavailable | TR velocity ≤ 2.8 m/s → normal; > 2.8 m/s → elevated |
Pulmonary Hypertension
The aim here is to determine whether the echocardiographic pattern favours pre-capillary or post-capillary physiology. Right heart catheterisation remains definitive when haemodynamic classification is clinically required. Use lateral E/e′ rather than average, because elevated RV pressures displace the septum and make septal e′ unreliable.
| Finding | Favours |
|---|---|
| E/A ≤ 0.8 with E ≤ 50 cm/s | Pre-capillary PH, normal LAP |
| E/A ≥ 2 with reduced e′ | Post-capillary (group 2) PH, elevated LAP |
| E/A 0.8 – 2, or E/A ≤ 0.8 with E > 50 cm/s → LARS > 18% | Normal LAP |
| Same intermediate group → LARS ≤ 18% | Elevated LAP |
| LARS unavailable → lateral E/e′ < 8 / > 13 / 8–13 | Normal / elevated / indeterminate |
Indicators of Elevated LV Filling Pressure in Other Populations
| Population | Key indicators of elevated LV filling pressure |
|---|---|
| Sinus tachycardia | Predominant early filling with depressed EF; IVRT ≤ 70 ms; average E/e′ > 14. When E and A are fused, the compensatory pause after a premature beat may separate the waves. |
| Hypertrophic cardiomyopathy | Average E/e′ > 14; Ar–A ≥ 30 ms; peak TR velocity > 2.8 m/s; LA maximum volume index > 34 mL/m². |
| Restrictive cardiomyopathy | Average E/e′ > 14; DT < 140 ms; E/A > 2.5; IVRT < 50 ms; septal and lateral e′ 3–4 cm/s. These are specific but not sensitive. |
| Mitral stenosis | IVRT < 60 ms; mitral A peak velocity > 1.5 m/s; IVRT/TE-e′ < 4.2. |
| Mitral regurgitation | IVRT < 60 ms; Ar–A ≥ 30 ms; IVRT/TE-e′ < 5.6; average E/e′ > 14 when EF is depressed. |
| LV assist device | E/A > 2; RAP > 10 mmHg; PASP > 40 mmHg; average E/e′ > 14 or septal E/e′ ≥ 15; LAVi > 33 mL/m²; interatrial septum position. |
Measurement Pitfalls
| Measurement | Pitfall | Impact |
|---|---|---|
| Mitral e′ (TDI) | Sample volume not at the annulus | Distorts e′. Place at or within 1 cm of the annular insertion. |
| Mitral e′ (TDI) | Annular calcification distorting tissue motion | e′ unreliable in moderate–severe MAC. Use the MAC pathway. |
| Mitral E velocity | Sample volume not at the leaflet tips | E is maximal at the tips; placement further into the LV underestimates it. |
| Mitral E/A | E–A fusion with tachycardia | E/A uninterpretable when fused. Where E at the onset of A exceeds 20 cm/s, A is artefactually elevated and may mimic impaired relaxation. Use a compensatory pause, or DT and TDI instead. |
| Mitral E velocity | Significant MR increasing transmitral flow | E is raised by volume overload, not LAP alone — E/A and E/e′ may overstate severity. |
| TR velocity | Incomplete envelope or non-parallel alignment | Underestimates PASP. Use multiple windows; an ultrasound-enhancing agent may improve the signal. |
| TR velocity | Elevated TR in non-cardiac PH | Reflects pulmonary pressure, not LAP. Use the PH pathway, which avoids TR as a primary variable. |
| E/e′ ratio | Septal e′ with septal wall motion abnormality, LBBB or RV pacing | Septal e′ unreliable. Use lateral E/e′. |
| LA volume | Foreshortened views or wrong phase | LAVi is measured at end-systole, just before mitral valve opening. Foreshortening underestimates it. |
| All Doppler | Not averaging across cycles | Average ≥ 3 cycles in sinus rhythm and ≥ 5 in atrial fibrillation. |
Constriction versus Restriction
Both present with diastolic heart failure, elevated filling pressures and preserved EF. The distinction matters because constriction is surgically treatable. The 2025 guideline's Figure 7 approach begins with mitral E/A > 0.8 and a dilated IVC, then assesses respirophasic septal motion and medial e′.
| Parameter | Constriction | Restriction |
|---|---|---|
| Respirophasic septal shift / septal bounce | Present — characteristic | Absent |
| Medial annular e′ | > 7 cm/s (annulus paradoxus); > 8 cm/s favours constriction | < 5 cm/s; < 6 cm/s favours restriction |
| Medial versus lateral e′ | Medial ≥ lateral (annulus reversus) | Lateral > medial (normal pattern) |
| Mitral inflow respiratory variation | > 25% (tricuspid > 40%) | Typically minimal |
| Hepatic vein flow | Expiratory diastolic reversal / forward ratio ≥ 0.8 | Systolic or inspiratory reversal |
| Longitudinal strain | Relatively preserved GLS; strain reversus (lateral < septal) | Reduced GLS; apical sparing in amyloidosis |
| Wall thickness | Normal | May be increased — amyloid, Fabry, haemochromatosis |
| Pericardium | May be thickened, but thickness is not required for the diagnosis | Normal; small effusion possible in amyloid |
Reporting Checklist
The guideline recommends that reports state both the diastolic function grade and the filling-pressure conclusion wherever possible. Where a grade cannot be assigned, the filling-pressure status should still be reported.
| Report | Detail |
|---|---|
| Context | Rhythm, heart rate and blood pressure at the time of the study |
| Grade | Normal, Grade 1, Grade 2, Grade 3, or indeterminate |
| Mean LAP | Normal, elevated, or indeterminate — stated separately from the grade |
| Always include | Mitral inflow velocities, mitral annular e′, E/A, average E/e′, peak TR velocity |
| Include if relied upon | LARS, PV S/D ratio, mitral A duration, PV Ar duration, IVRT |
| Algorithm used | State when a special-population pathway was applied instead of the sinus rhythm algorithm |
| Comparison | Note any change from the previous study |
| Further assessment | Recommend diastolic exercise echocardiography where clinically appropriate |
What Changed in 2025
| Change | Practical effect |
|---|---|
| Diagnosis separated from LAP estimation | Age-specific e′ cut-offs for diagnosing dysfunction; age-independent cut-offs within the LAP algorithm |
| Revised three-variable resting algorithm | e′, E/e′ and TR/PASP assessed simultaneously rather than sequentially |
| LA reservoir strain incorporated | LARS ≤ 18% now a primary supplementary criterion and a discriminator in AF and PH |
| Dedicated phenotype pathways | Distinct algorithms for AF, moderate–severe MAC, pulmonary hypertension and transplantation |
| Closer integration with HFpEF | Explicit role for diastolic exercise echocardiography in symptomatic patients with normal or indeterminate resting findings |
| Reporting requirements strengthened | Grade and filling pressure both reported; indeterminate is an acceptable conclusion |
Frequently Asked Questions
Which e′ cut-offs should I use — age-specific or fixed?
Both, for different purposes. Use the age-specific cut-offs (septal < 7 / < 6 / < 6 cm/s for ages 20–39, 40–65 and over 65) when answering whether diastolic dysfunction is present. Use the age-independent cut-offs (septal ≤ 6, lateral ≤ 7, average ≤ 6.5 cm/s) within the filling-pressure algorithm. Applying the age-specific values inside the LAP algorithm, or the fixed values to the diagnostic step, is a common error.
How do you estimate left atrial pressure in atrial fibrillation?
Average measurements over at least five cycles and assess four variables: mitral E ≥ 100 cm/s, septal E/e′ > 11, TR velocity > 2.8 m/s or PASP > 35 mmHg, and deceleration time ≤ 160 ms. Three or more abnormal indicates elevated LAP; none or one indicates normal LAP. With exactly two abnormal, apply the secondary criteria — LARS < 18%, pulmonary vein S/D < 1 and BMI > 30 kg/m². The E/A ratio cannot be used, and LARS should not be used as a standalone marker.
When should diastolic stress echocardiography be performed?
Consider it in symptomatic patients with Grade 1 diastolic dysfunction, indeterminate resting filling pressure, or a high clinical suspicion of HFpEF despite an apparently normal resting study. A positive result requires an elevated average E/e′ (≥ 14) or septal E/e′ (≥ 15) together with an elevated peak TR velocity, since E/e′ rises with exercise in normal subjects as well.
How do you distinguish constrictive pericarditis from restrictive cardiomyopathy?
The two most useful findings are respirophasic ventricular septal shift and the medial annular e′ velocity. Medial e′ above 7 cm/s despite heart failure — annulus paradoxus — favours constriction, while values below 5 cm/s favour restriction. Combined, these two steps give roughly 80% sensitivity and 96% specificity. Supporting features for constriction include annulus reversus, mitral inflow respiratory variation above 25%, and expiratory hepatic vein diastolic flow reversal. Normal pericardial thickness does not exclude constriction.
- Nagueh SF, Sanborn DY, Oh JK, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography and for Heart Failure With Preserved Ejection Fraction Diagnosis: An Update From the American Society of Echocardiography. J Am Soc Echocardiogr. 2025;38(7):537–569. doi:10.1016/j.echo.2025.03.011
- Lang RM, et al. Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr. 2015;28:1–39.
- Welch TD, et al. Echocardiographic Diagnosis of Constrictive Pericarditis: Mayo Clinic Criteria. Circ Cardiovasc Imaging. 2014;7(3):526–534.
- Klein AL, et al. American Society of Echocardiography Clinical Recommendations for Multimodality Cardiovascular Imaging of Patients with Pericardial Disease. J Am Soc Echocardiogr. 2013;26(9):965–1012.