Echocardiographic evaluation of left ventricular diastolic function
- Sherif F Nagueh, MD, FACC, FAHA, FASE
Sherif F Nagueh, MD, FACC, FAHA, FASE
- Professor of Medicine
- Weill Cornell Medical College
Left ventricular (LV) diastolic function can be characterized by invasive and noninvasive methods. Invasive measures of diastolic function include the peak instantaneous rate of LV pressure decline (-dP/dt), the time constant of LV relaxation (tau), and the stiffness modulus. Although echocardiography does not directly measure these parameters, echocardiography is the most practical routine clinical approach for evaluating LV diastolic function given clinical and experimental evidence supporting its use as well as its safety, versatility, and portability. (See "Pathophysiology of diastolic heart failure".)
Diastole is conventionally divided into the following phases: isovolumetric relaxation (both aortic and mitral valves are closed and LV pressure is declining), early LV filling with opening of the mitral valve, a mid-diastolic phase (often noted in patients with bradycardia), and late or atrial filling with left atrial (LA) contraction. In normal hearts, predominant LV filling occurs in early diastole. With impaired LV relaxation, LV filling shifts to late diastole and becomes dependent on LA systolic function. This accounts for the significant clinical deterioration that is seen in patients with diastolic dysfunction (such as hypertrophic cardiomyopathy) in the presence of atrial fibrillation.
Diastolic dysfunction by echocardiography is one of the criteria for the diagnosis of heart failure with preserved ejection fraction (HFpEF) . This topic summarizes available echocardiographic methods for assessment of LV diastolic function. Recommendations in this topic are generally in agreement with the American Society of Echocardiography recommendations for the evaluation of LV diastolic function by echocardiography .
Diagnosis, management, and prognosis of HFpEF are discussed separately. (See "Clinical manifestations and diagnosis of heart failure with preserved ejection fraction" and "Treatment and prognosis of heart failure with preserved ejection fraction".)
DIAGNOSIS AND EVALUATION
When to suspect diastolic dysfunction — Left ventricular (LV) diastolic dysfunction should be suspected in patients with known or suspected heart failure (eg, patients with possible cardiogenic dyspnea) as well as in asymptomatic patients with hypertension. LV diastolic dysfunction can cause symptoms of dyspnea and reduced exercise tolerance in patients with heart failure with reduced ejection fraction and heart failure with preserved ejection fraction. Thus, assessment of diastolic function is an integral component of the echocardiographic examination in patients referred with a diagnosis of dyspnea or heart failure. Evaluation of diastolic function in asymptomatic patients with hypertension is also reasonable, as echocardiographic findings of diastolic dysfunction and its progression or lack thereof have been shown to predict clinical events of death and heart failure in observational and community studies. (See "Treatment and prognosis of heart failure with preserved ejection fraction", section on 'Asymptomatic diastolic dysfunction'.)
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- DIAGNOSIS AND EVALUATION
- When to suspect diastolic dysfunction
- Approach to diagnosis and evaluation
- - Initial clinical and echocardiographic assessment
- - Echocardiographic diagnosis of diastolic dysfunction
- - Limitations and caveats
- GRADING DIASTOLIC DYSFUNCTION
- ESTIMATION OF LEFT ATRIAL PRESSURE
- INDICATORS OF DIASTOLIC FUNCTION
- Summary of indicators
- Doppler mitral inflow velocity
- Pulmonary venous flow
- Tissue Doppler imaging
- Color flow mapping
- Alternate approach
- SUMMARY AND RECOMMENDATIONS