🫀

ASE 2025 Diastolic Function

Interactive Clinical Reference · Nagueh et al. JASE 2025

LV Diastolic Function Algorithm

Interactive version of Figure 3 from the 2025 ASE Guidelines. Click any node to see clinical detail and cutoff values.

⚠️ For educational and reference use only. Always integrate findings with full clinical context. Not a substitute for individual clinical judgment.
Three Variables Assessed Simultaneously
① e' velocity
Sep ≤6 / Lat ≤7 / Avg ≤6.5 cm/s
② E/e' ratio
Sep ≥15 / Lat ≥13 / Avg ≥14
③ TR / PASP
TR ≥2.8 m/s or PASP ≥35 mmHg
All Normal
✅ Normal DF
Normal LAP
Reduced e' Only
E/e' and TR/PASP normal
E/A ≤0.8
🟡 Grade 1 DD
Normal LAP
E/A >0.8
→ Suppl.
🟡 Grade 1 DD
Impaired relaxation · Normal LAP
🚴 Exercise Echo
If symptomatic
↑TR/PASP only
— or — ↑E/e' only
— or — any 2 abnormal
📋 Supplemental
PV S/D ≤0.67
LARS ≤18%
LAVi >34 mL/m²
IVRT ≤70 ms
None present
🟡 Grade 1 DD
Normal LAP
≥1 present
🔴 ↑ LAP
🚴 Exercise Echo
If symptomatic + normal LAP
All 3 Abnormal
↑ LAP confirmed
🔴 Increased LAP
Grade by E/A ratio
E/A <2
Grade 2 DD
Mild–Mod ↑ LAP
E/A ≥2
Grade 3 DD
Marked ↑ LAP
⚠
Algorithm Exclusions — see Special Populations tab
Severe MR · Any MS · Mod/severe MAC · Afib · Heart transplant · Non-cardiac PH · Pericardial constriction · LVAD · MV repair/replacement/TEER
👆 Click any box for detailed cutoffs, physiology, and clinical pearls
Algorithm Step
Decision Point
Normal
Grade 1
Grade 2
Grade 3
Action
👆

Click any node

Select a step or grade in the algorithm to see detailed clinical information and cutoff values.

Diastolic Function Calculator

Enter echocardiographic measurements to estimate LV filling pressure and diastolic dysfunction grade per the 2025 ASE Algorithm.

⚠️ This tool is for educational reference only. Applies to patients in sinus rhythm without exclusion criteria (severe MR/MS, significant MAC, atrial fibrillation, heart transplant, non-cardiac PH, pericardial constriction, or LVAD).
📋 Patient Information
🔬 Primary Measurements
📊 Supplemental Parameters (if available)
📈 Result
🩺
Enter measurements and click Analyze

Special Populations

Section 15 of the 2025 ASE Guidelines — modified approaches for conditions requiring deviation from the general algorithm.

💓
Atrial Fibrillation
Multiparametric approach; no single reliable marker
🫁
Pulmonary Hypertension
Lateral E/e' preferred; LARS for confirmation
🦴
Mitral Annular Calcification
E/A + IVRT-based algorithm
❤️
Hypertrophic Cardiomyopathy
Comprehensive Doppler approach required
🔄
Mitral Regurgitation
IVRT/TE-e', Ar-A duration; E/e' limited in primary MR
🏥
Heart Transplant Recipients
Simplified E/e' + SRIVR algorithm
🩻
Restrictive Cardiomyopathy
Amyloidosis features, grade 3 indicators
🔒
Pericardial Constriction
Differentiation from restrictive cardiomyopathy
⚡
LBBB / Pacing / AV Block
Conduction effects on diastolic indices
💓

Atrial Fibrillation

No single parameter sufficient; multiparametric approach with moderate accuracy

🔢 Interactive: AF LAP Estimator

Select parameters that meet the cutoff thresholds (values averaged over multiple cycles):

Secondary parameters (if ≥2 above):

Key Principles

  • 1
    Average values from several cycles; select cycles reflecting average HR
  • 2
    Dual Doppler probe for simultaneous E and e' improves PCWP estimation
  • 3
    Less beat-to-beat mitral inflow variability → more likely elevated LAP
  • ✗
    LARS should not be used as a standalone marker of LAP in AF — only as a secondary discriminator when ≥2 primary criteria are met (per Figure 8)
  • ✗
    Pulmonary vein Ar velocity absent in AF

LAP Criteria in AF

ParameterElevated LAP
Mitral E velocity≥100 cm/s
Septal E/e'>11
TR velocity>2.8 m/s
PASP>35 mmHg
Decel time (DT)≤160 ms
PV DT≤220 ms
E/Vp ratio≥1.4

📌 Key Points — AF

  • No single parameter has sufficiently strong association with LV filling pressure in AF
  • A multiparametric approach can differentiate normal from elevated LAP with moderate accuracy
  • 3 or more of the 4 primary parameters → elevated LAP; none or 1 → normal LAP; 2 → indeterminate
  • Secondary criteria (LARS <18%, PV S/D <1, BMI >30) applied when 2 primary are met
🫁

Pulmonary Hypertension

Lateral E/e' preferred due to septal flattening; LARS confirms

🔢 Interactive: PH LAP Algorithm

Algorithm (Figure 6)

E/A ratio assessment
↓
E/A ≤0.8 + E ≤50
Normal LAP
Precapillary PH likely
E/A ≥2 + e' reduced
Elevated LAP
Group II PH likely
E/A 0.8–2 or E/A ≤0.8 but E >50 → check LARS:
LARS >18%
Normal LAP
LARS ≤18%
Elevated LAP
If LARS unavailable: Lateral E/e' <8 = normal; >13 = elevated; 8-13 = indeterminate

Key Cutoffs

ParameterNormalElevated
E/A ratio≤0.8≥2
Lateral E/e'<8>13
LARS>18%≤18% (Fig. 6 algorithm)
LAVi≤34 mL/m²>34 mL/m²
Note: Use lateral E/e' (not average) due to septal displacement from elevated RV pressures. Septal e' may be unreliable.

📌 Key Points — Pulmonary Hypertension

  • E/A ≤0.8 favors precapillary PH; E/A ≥2 favors postcapillary (group II) PH
  • LAVi >34 mL/m², lateral E/e' >13, and LARS ≤18% all favor group II PH (Figure 6 algorithm uses ≤18%; one study used ≤16% with lateral E/e' — that is study-specific)
  • Lateral E/e' 8–13 has weak/no association with LAP → indeterminate zone
  • Combining lateral E/e' with E/A or LARS improves diagnostic accuracy
🦴

Mitral Annular Calcification (MAC)

E/e' unreliable due to mechanical effects; use E/A + IVRT algorithm

🔢 Interactive: MAC LAP Algorithm (Figure 4)

⚠ E/e' Caution: Moderate–severe MAC increases diastolic transmitral velocities (reduced mitral orifice area) and decreases lateral e' (reduced annular excursion). This artificially elevates E/e' — do not rely on E/e' alone in significant MAC.

📌 Key Points — MAC

  • E/A <0.8 → normal LAP; E/A >1.8 → elevated LAP
  • E/A 0.8–1.8: measure IVRT — ≥80 ms suggests normal; <80 ms suggests elevated LAP
  • Standard E/e' ratio unreliable due to mechanical MAC effects on both velocities
  • IVRT can be helpful to identify elevated LAP in this population
❤️

Hypertrophic Cardiomyopathy (HCM)

Diastolic dysfunction ubiquitous; comprehensive multiparameter approach

Recommended Parameters

  • ✓
    Mitral inflow velocities (E, A, DT)
  • ✓
    Pulmonary vein velocities (S, D, Ar)
  • ✓
    Mitral annular velocities (e', a')
  • ✓
    Peak TR velocity (CW Doppler)
  • ✓
    Biplane LA volumes
  • ✓
    Ar-A duration (for LVEDP, if no AF/block)

Indicators of Elevated LAP in HCM

ParameterCutoff
Average E/e'>14
Ar-A duration≥30 ms
Peak TR velocity>2.8 m/s
LA max volume index>34 mL/m²

📌 Key Points — HCM

  • Impaired LV relaxation is an early finding — may precede LV hypertrophy in mutation carriers
  • Diastolic dysfunction present irrespective of hypertrophy pattern or obstruction
  • Restrictive LV filling + increased E/e' → HF hospitalizations, reduced exercise tolerance, sudden cardiac death risk
  • MR does not affect PV Ar velocity — useful even when significant MR present
  • LA reservoir and pump strains associated with functional capacity and AF development
🔄

Mitral Regurgitation (MR)

E/e' limited in primary MR with normal EF; IVRT/TE-e' and Ar-A duration preferred

Preferred Indicators

  • ✓
    IVRT <60 ms → elevated LAP (specific, not sensitive)
  • ✓
    Ar-A duration ≥30 ms → elevated LVEDP (irrespective of MR severity)
  • ✓
    IVRT/TE-e' <5.6 → predicts elevated PCWP
  • ✗
    E/e' ratio: not useful in primary MR + normal EF
  • ✗
    LARS: no significant relationship with LA pressure in significant MR

Additional Findings

Primary MR physiology: Increases LA and LV compliance → attenuates LAP elevation early. Moderate–severe MR ↑ mitral E velocity and ↓ PV systolic velocity regardless of LV dysfunction.
Secondary MR: E/e' ratio does correlate with LAP in patients with depressed EF and secondary MR, and predicts hospitalizations + mortality.
After TEER/valve repair: Time intervals and PA pressures may be useful; formal E/e' accuracy is reduced.

📌 Key Points — MR

  • Ar-A duration ≥30 ms remains a reliable LVEDP indicator regardless of MR severity
  • CW Doppler MR velocity profile with early peaking and reduced late gradient → highly specific (not sensitive) for elevated LAP
  • E/e' may be considered in patients with depressed EF and secondary MR
  • IVRT/TE-e' <5.6 predicts PCWP >15 mmHg in MR patients with and without normal EF (Table 7); IVRT/TE-e' <3 is an alternative cutoff specifically predicting PCWP >15 mmHg in patients with depressed EF
🏥

Heart Transplant Recipients

Denervated heart; simplified E/e' algorithm with SRIVR for indeterminate cases

🔢 Interactive: Transplant LAP Algorithm (Figure 5)

Algorithm Cutoffs

ParameterNormal LAPElevated LAP
Average E/e'<7>14
E/SRIVR≤200 cm>200 cm
Peak TR vel≤2.8 m/s>2.8 m/s

Special Considerations

  • 1
    Denervated heart → sinus tachycardia → E/A fusion common
  • 2
    E/A ≥2 with preserved EF common in early post-transplant (normal finding)
  • 3
    PV S/D ratio unreliable (reduced S/D in young donor hearts)
  • !
    No single parameter predicts graft rejection reliably

📌 Key Points — Heart Transplant

  • Predominant early diastolic filling in preserved EF is a common normal finding post-transplant
  • For E/e' 7–14: SRIVR from all 3 apical views → E/SRIVR ≤200 cm = normal; >200 cm = elevated
  • If SRIVR unavailable: TR velocity ≤2.8 m/s = normal; >2.8 m/s = elevated
  • LV diastolic dysfunction is a sensitive sign of early graft rejection (myocardial edema)
🩻

Restrictive Cardiomyopathy

Includes cardiac amyloidosis; advanced disease → grade 3 DD with specific features

Advanced Disease Indicators

ParameterFinding
E/A ratio>2.5 *
E decel time (Table 7)<140 ms *
IVRT<50 ms *
Average E/e'>14
Septal e'3–4 cm/s
Lateral e'3–4 cm/s
LV GLSDecreased
LA strainReduced

* Specific but not sensitive. DT <140 ms is the Table 7 special-population cutoff; advanced disease is often described as DT <150 ms in the text.

Cardiac Amyloidosis "Red Flags"

  • !
    Increased LV and RV wall thickness
  • !
    Biatrial enlargement
  • !
    Preserved EF with low stroke volume index
  • !
    Paradoxical low-flow, low-gradient AS association
  • !
    "5-5-5 sign": s', e', a' all <5 cm/s
  • !
    Apical sparing on LV longitudinal strain (polar plot)

📌 Key Points — Restrictive Cardiomyopathy

  • Early disease: grade 1 DD; progresses to grade 2 then grade 3 as severity increases
  • Cardiac amyloidosis: apical sparing on LV strain is characteristic (apical/mid+basal ratio >1)
  • "5-5-5 sign" (s', e', a' all <5 cm/s) in advanced amyloidosis
  • Grade 3 diastolic dysfunction associated with poor outcome
  • Distinction from pericardial constriction critical — see Pericardial Constriction tab
🔒

Pericardial Constriction

Key features distinguish from restrictive cardiomyopathy (Figure 7 algorithm)

Features Supporting Constriction

  • ✓
    Respirophasic ventricular septal shift
  • ✓
    Septal bounce
  • ✓
    Mitral inflow variation with respiration >25%
  • ✓
    Tricuspid inflow variation >40%
  • ✓
    Medial annular e' >7 cm/s (annulus paradoxus)
  • ✓
    Annulus reversus: septal e' > lateral e'
  • ✓
    Expiratory hepatic vein reversal/forward ≥0.8
  • ✓
    Strain reversus: lateral/RV strain < septal strain

Constriction vs. Restriction

FeatureConstrictionRestriction
Medial e'>7 cm/s<5 cm/s
Septal motionRespirophasicNormal
Annulus reversusPresentAbsent
Hepatic vein expReversal ≥0.8Systolic rev
Figure 7 algorithm: Steps 1 (respirophasic septal motion) + 2 (medial e') → 80% sensitivity, 96% specificity when both positive.

📌 Key Points — Pericardial Constriction

  • Normal or increased medial annular e' in a patient with HF should raise suspicion for constriction
  • Algorithm: mitral E/A >0.8 + dilated IVC → check respirophasic septal motion
  • Medial e' >8 cm/s → likely constriction; <6 cm/s → likely restriction
  • Annulus reversus (septal > lateral e') and strain reversus are specific for constriction
⚡

LBBB, RV Pacing & AV Block

Conduction abnormalities reduce reliability of standard diastolic indices

LBBB Effects

  • !
    Prolonged IVRT → shortened LV filling time
  • !
    Septal e' reduced → septal and average E/e' unreliable
  • ✓
    Lateral e' may still indicate filling pressure
  • ✓
    TR velocity useful if only mitral A present

1st Degree AV Block

  • ✓
    Variables valid if no E/A fusion
  • !
    PR >280 ms + impaired relaxation → E/A fusion
  • !
    PR >320 ms → uniphasic A + diastolic MR

RV Pacing

  • !
    Induces LV dyssynchrony (LBBB-like pattern)
  • !
    Septal e' unreliable as marker of DD
  • ✓
    Complete fusion: TR velocity + LA volume/strain
Note on E/A Fusion: When E at onset of A >20 cm/s, A velocity is elevated (shorter diastole → smaller LV volume at onset of atrial contraction). This may mimic impaired relaxation.

📌 Key Points — Conduction Abnormalities

  • Right BBB: minimal clinically meaningful changes to diastolic indices
  • LBBB/RV pacing: septal and average E/e' less reliable; lateral E/e' preferred
  • Complete E/A fusion: use peak TR velocity, LA volume, and LARS to assess LAP
  • LARS accuracy in the LBBB/pacing setting has not been critically examined

Normal Reference Ranges

Table 5 from the 2025 ASE Guidelines. Age-stratified 5th–95th percentile values in subjects free of cardiovascular disease or risk factors.

⚠️ Normal ranges are not equivalent to "optimal" values. Aging affects diastolic function. Use age-specific ranges for clinical interpretation. LAVi differs by measurement method.
📊 Transmitral Flow
Parameter5th %ile95th %ile
E wave (m/s)0.541.11
A wave (m/s)0.240.68
E/A ratio0.882.73
📊 Tissue Doppler
Parameter5th %ile95th %ile
e' lateral (cm/s)9.922.1
e' septal (cm/s)7.216.4
e' average (cm/s)8.719.1
E/e' lateral2.56.3
E/e' septal4.09.1
E/e' average4.0 †9.1 †
📊 LA Volume & Strain
Parameter5th %ile95th %ile
LAVi biplane (mL/m²)12.541.9
LA strain LARS (%)29.563.2

† E/e' average (4.0–9.1) is identical to septal values for ages 20–39 as published in Table 5 of the guideline. Verify against the original PDF if using for clinical reference.

📊 Other
Parameter5th %ile95th %ile
TR velocity (m/s)1.32.7
Sex differences: Statistical differences noted for E and A velocities by sex, but not E/A ratio or other parameters assessed.
📊 Transmitral Flow
Parameter5th %ile95th %ile
E wave (m/s)0.471.02
A wave (m/s)0.330.82
E/A ratio0.692.07
📊 Tissue Doppler
Parameter5th %ile95th %ile
e' lateral (cm/s)7.517.5
e' septal (cm/s)5.713.5
e' average (cm/s)6.715.4
E/e' lateral3.69.4
E/e' septal4.912.1
E/e' average4.611.5
📊 LA Volume & Strain
Parameter5th %ile95th %ile
LAVi biplane (mL/m²)13.341.0
LA strain LARS (%)26.857.7
📊 Other
Parameter5th %ile95th %ile
TR velocity (m/s)1.52.7
📊 Transmitral Flow
Parameter5th %ile95th %ile
E wave (m/s)0.390.92
A wave (m/s)0.430.97
E/A ratio0.501.40
📊 Tissue Doppler
Parameter5th %ile95th %ile
e' lateral (cm/s)5.213.0
e' septal (cm/s)4.110.6
e' average (cm/s)4.711.7
E/e' lateral4.812.6
E/e' septal5.915.2
E/e' average5.214.0
📊 LA Volume & Strain
Parameter5th %ile95th %ile
LAVi biplane (mL/m²)14.240.0
LA strain LARS (%)24.152.3
📊 Other + Age-Related Changes
Parameter5th %ile95th %ile
TR velocity (m/s)1.72.8
Age effect: E ↓, A ↑, E/A ↓, e' ↓, E/e' ↑, LARS ↓ with age. Normal ranges ≠ optimal values.

📌 Key Points on Normal Ranges

  • Derived from 5th–95th percentiles in subjects free of cardiovascular disease or risk factors
  • E/e' ratio and LAVi have near-linear associations with HF incidence without a clear threshold
  • For LARS: values differ by speckle-tracking software vendor — results may not be interchangeable
  • LAVi differs by measurement method: biplane method of disks vs. area-length method
  • Prognostic thresholds may occur within "normal" ranges — clinical context essential

Diastolic Dysfunction Grading

Comprehensive reference for diagnosis of diastolic dysfunction (Figure 2) and grade classification.

📋 Step 1: Assess e' Velocity (LV Relaxation)
Age GroupSeptal e'Lateral e'Average e'
20–39 y<7 cm/s<10 cm/s<9 cm/s
40–65 y<6 cm/s<8 cm/s<7 cm/s
>65 y<6 cm/s<7 cm/s<6.5 cm/s
If e' is reduced → only 1 additional Step 2 criterion needed for DD diagnosis
If e' is preserved → 2 Step 2 criteria needed
📋 Step 2: LAP Markers & Structural Surrogates
ParameterCutoff (Abnormal)Role
Average E/e' ratio>14↑ LAP marker
LA Reservoir Strain (LARS)≤18%↑ LAP marker
E/A ratio (high)≥2↑ LAP marker
TR velocity (peak CW)≥2.8 m/s↑ LAP marker ⚠
PASP≥35 mmHg↑ LAP marker ⚠
E/A ratio (low)≤0.8Impaired relaxation (not ↑ LAP)
LAVi (biplane)>34 mL/m²Structural surrogate
LV mass index (women)>95 g/m²Structural surrogate
LV mass index (men)>115 g/m²Structural surrogate
⚠ E/A ≤0.8 reflects impaired LV relaxation and helps diagnose DD, but does not indicate elevated LAP. Elevated LAP is supported by E/A ≥2, E/e' >14, LARS ≤18%, and ↑ TR/PASP.
⚠ TR velocity / PASP caveat: TR ≥2.8 m/s or PASP ≥35 mmHg supports elevated LAP only in the absence of primary pulmonary disease or pulmonary arterial hypertension. In patients with known PH or significant lung disease, elevated TR/PASP reflects pulmonary vascular disease rather than elevated LV filling pressures and should not be counted as a LAP marker.
🟡
Grade 1 DD
Impaired relaxation pattern
  • •
    Reduced e' velocity
  • •
    E/A ≤0.8
  • •
    Normal mean LAP
  • •
    LVEDP may be elevated
If symptomatic: refer for diastolic exercise echo
🔴
Grade 2 DD
Pseudonormal filling pattern
  • •
    Reduced e' velocity
  • •
    E/A 0.8–2 (or appears normal)
  • •
    ≥1 LAP marker elevated
  • •
    Mild–moderate ↑ LAP
Valsalva: E/A drops ≥50% (distinguishes from Grade 1)
🔴🔴
Grade 3 DD
Restrictive filling pattern
  • •
    Markedly reduced e'
  • •
    E/A ≥2
  • •
    Short DT (<160 ms)
  • •
    Marked ↑ LAP
Reversible (Grade 3a) vs. irreversible (3b): E/A <2 with Valsalva = reversible
📋 LAP Estimation Algorithm Cutoffs (Figure 3 Reference)
ParameterReduced / AbnormalNormalComments
Septal e' velocity≤6 cm/s>6 cm/sAge-independent cutoff for algorithm Step 1
Lateral e' velocity≤7 cm/s>7 cm/sAge-independent cutoff for algorithm Step 1
Average e' velocity≤6.5 cm/s>6.5 cm/sAge-independent cutoff for algorithm Step 1
Average E/e'>14 (↑ LAP)<8 (normal)8–14 = gray zone; 14+ = high specificity for ↑ LAP
Septal E/e'≥15 (↑ LAP)<10 (normal)Also used for exercise echo interpretation
Lateral E/e'≥13 (↑ LAP)<8 (normal)Preferred in PH (use lateral not average)
TR velocity≥2.8 m/s<2.8 m/sSupports ↑ LAP in absence of pulmonary disease
PASP≥35 mmHg<35 mmHgUse when RAP estimable
LARS≤18%>24%18–24% = low normal (higher sensitivity, lower specificity)
PV S/D ratio≤0.67>0.67Reliable mainly in reduced LVEF; unreliable in normal EF
LAVi (biplane)>34 mL/m²≤34 mL/m²Supplemental; after excluding athletes, anemia, AF, MV disease
IVRT≤70 ms (↑ LAP)>110 ms (likely normal)Supplemental parameter in algorithm

📌 Reporting Requirements (Section 12)

  • Reports should include diastolic function grade and filling pressure (LAP normal or elevated) whenever possible; if grade cannot be determined, filling pressure status should still be mentioned
  • Always report: mitral inflow velocities, mitral annular e', peak TR velocity, E/A ratio, average E/e'
  • Include if relied upon: LARS, PV S/D ratio, mitral A duration, PV Ar duration, IVRT
  • Note any change from previous study when available
  • Isolated ↑ LVEDP should be reported — predisposes to elevated mean LAP with exercise/tachycardia
Citation: 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;38:537–569.

📄 Download full guidelines from ASE website  |  DOI: 10.1016/j.echo.2025.03.011

This interactive tool is for educational and clinical reference purposes only. It does not replace clinical judgment or individualized patient assessment. Always refer to the full guideline document for complete recommendations. Content © 2025 American Society of Echocardiography.