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Echocardiography📍 HeartUpdated on 2026-01-20Radiology reviewed

Diastolic Dysfunction on Echocardiography

Understand Diastolic Dysfunction on Echocardiography in Heart Echocardiography imaging, what it means, and next steps.

30-Second Overview

Definition

Abnormal mitral inflow pattern (E/A ratio alterations), increased left atrial size, elevated E/e' ratio, reduced tissue Doppler e' velocity, pulmonary venous flow abnormalities.

Clinical Significance

Diastolic dysfunction indicates impaired heart relaxation and filling. Often associated with hypertension, aging, and coronary disease. Grade II or higher diastolic dysfunction indicates increased risk of heart failure symptoms.

Benign Rate

benignRate

Follow-up

followUp

Imaging Appearance

Echocardiography Finding

Abnormal mitral inflow pattern (E/A ratio alterations), increased left atrial size, elevated E/e' ratio, reduced tissue Doppler e' velocity, pulmonary venous flow abnormalities.

Clinical Significance

Diastolic dysfunction indicates impaired heart relaxation and filling. Often associated with hypertension, aging, and coronary disease. Grade II or higher diastolic dysfunction indicates increased risk of heart failure symptoms.

Understanding Diastolic Dysfunction on Echocardiography

Diastolic dysfunction occurs when the heart's pumping chambers (ventricles) become stiff and cannot relax properly, making it difficult for the heart to fill with blood between beats. This condition is increasingly common with aging and is a key feature of heart failure with preserved ejection fraction (HFpEF).

Echocardiography is the primary diagnostic tool for evaluating diastolic function, providing real-time images and measurements of how the heart relaxes and fills with blood.

What Is Diastolic Dysfunction?

Diastole is the phase of the cardiac cycle when the heart relaxes and fills with blood. Diastolic dysfunction means this relaxation process is impaired, which can lead to elevated pressures in the heart and lungs, even when the heart's pumping function appears normal.

The Cardiac Cycle: Diastole Explained

Normal diastole involves four phases:

  1. Isovolumic relaxation: Ventricles relax, all valves closed
  2. Early filling (E wave): Rapid passive filling from atria
  3. Diastasis: Slow filling period
  4. Atrial contraction (A wave): Active atrial pumping

In diastolic dysfunction:

  • The ventricle is stiff and relaxes slowly
  • Early filling is reduced
  • The atrium must work harder (higher pressure)
  • Eventually, pressures back up into the lungs

Grades of Diastolic Dysfunction

Grade I (Impaired Relaxation):

  • Mild dysfunction
  • Mitral inflow: E/A ratio ＜ 0.8
  • Filling pattern delayed
  • Usually asymptomatic
  • Often normal aging or hypertension

Grade II (Pseudonormal):

  • Moderate dysfunction
  • Mitral inflow: E/A ratio 0.8-2.0 (appears normal)
  • Elevated filling pressures
  • May have mild symptoms
  • Requires tissue Doppler to identify

Grade III (Reversible Restrictive):

  • Severe dysfunction
  • Mitral inflow: E/A ratio ＞ 2.0
  • Very high filling pressures
  • Symptomatic (dyspnea, edema)
  • May improve with treatment

Grade IV (Fixed Restrictive):

  • Very severe dysfunction
  • Mitral inflow: E/A ratio ＞ 2.0 (fixed)
  • Extremely high filling pressures
  • Severe symptoms
  • Poor prognosis

Epidemiology and Risk Factors

ModerateDiastolic dysfunction affects 25-30% of people over age 65

Grade II or higher diastolic dysfunction doubles the risk of developing heart failure and is associated with increased mortality. Early detection allows preventive measures.

Diastolic dysfunction becomes increasingly common with age:

Age distribution:

  • Under 50: Rare except with specific conditions
  • 50-65 years: Prevalence 15-20%
  • 65-80 years: Prevalence 25-30%
  • 80+ years: Prevalence 40% or higher

Major risk factors:

  • Age: Stiffening of heart tissue is age-related
  • Hypertension: Long-standing high blood pressure thickens heart muscle
  • Coronary artery disease: Ischemia impairs relaxation
  • Obesity: Associated with diastolic dysfunction
  • Diabetes: Causes myocardial changes
  • Valve disease: Especially aortic stenosis
  • Genetic factors: Some cardiomyopathies

Echocardiographic Assessment

Key Parameters Measured

When evaluating diastolic function, echocardiographers measure multiple parameters:

Sensitivity
80-90% for detecting diastolic dysfunction

Comprehensive evaluation using multiple parameters provides accurate diagnosis and grading

Specificity
85-95% with comprehensive evaluation

Correctly rules out healthy patients

Prevalence
25-30% of population over age 65

Annual new cases

Primary echocardiographic parameters:

  1. Mitral inflow pattern (pulsed-wave Doppler):

    • E wave: Early rapid filling
    • A wave: Atrial contraction
    • E/A ratio: Key diagnostic indicator
    • Deceleration time: Rate of early filling

  2. Tissue Doppler imaging (e' velocity):

    • Measures myocardial relaxation directly
    • Septal e': Normal ＞ 8 cm/s
    • Lateral e': Normal ＞ 10 cm/s
    • Less affected by loading conditions

  3. E/e' ratio:

    • Estimates left atrial pressure
    • Normal: ＜ 8
    • Elevated: ＞ 14 suggests high filling pressures

  4. Left atrial volume:

    • Enlarged LA suggests chronic elevation
    • Indexed to body surface area
    • Normal: ＜ 34 mL/m²

  5. Tricuspid regurgitation velocity:

    • Estimates pulmonary artery pressure
    • Normal: ＜ 2.8 m/s
    • Elevated: Suggests pulmonary hypertension

Comparing Normal and Abnormal Diastolic Patterns

Normal Diastolic Function

E/A ratio 1.0-1.5. E wave taller than A wave. Deceleration time 150-200 ms. Septal e' ＞ 8 cm/s, lateral e' ＞ 10 cm/s. E/e' ratio ＜ 8. Left atrium normal size. TR velocity ＜ 2.8 m/s.

Diastolic Dysfunction (Grade II)

Pseudonormal pattern with E/A ratio 1.0-1.5 (deceptively normal). E/e' ratio elevated (＞ 14). Reduced e' velocities (＜ 8 cm/s septal). Enlarged left atrium (＞ 34 mL/m²). Elevated TR velocity. Requires tissue Doppler for diagnosis.

Clinical Presentation

Typical Patient Scenario

Clinical Scenario

Patient68-year-old
Presenting withProgressive shortness of breath
6 months of worsening symptoms
ContextRetired teacher presents with gradually worsening dyspnea on exertion. Notices she can't walk as far as before. Reports mild ankle swelling at end of day. History of treated hypertension for 20 years. Mild obesity. No prior heart disease.
Imaging Indication:Comprehensive transthoracic echocardiogram to evaluate left ventricular function, assess for diastolic dysfunction, estimate pulmonary pressures, and evaluate valvular disease.

Symptoms and Detection

Early diastolic dysfunction (Grade I):

  • Usually asymptomatic
  • May have reduced exercise tolerance
  • Detected incidentally on echocardiogram

Moderate-severe dysfunction (Grade II-IV):

  • Exertional dyspnea: Shortness of breath with activity
  • Orthopnea: Difficulty breathing when lying flat
  • Exercise intolerance: Fatigue with exertion
  • Peripheral edema: Ankle and leg swelling
  • Abdominal bloating: Fluid retention
  • Reduced exercise capacity

Differential Diagnosis

Several conditions can cause or mimic diastolic dysfunction:

What Else Could It Be?

Grade I diastolic dysfunction (impaired relaxation)Moderate

E/A ratio ＜ 0.8, prolonged deceleration time (＞ 200 ms). Normal filling pressures at rest. Usually asymptomatic. Often age-related or from long-standing hypertension.

Grade II diastolic dysfunction (pseudonormal)Moderate

E/A ratio appears normal (0.8-2.0). Elevated E/e' ratio (＞ 14). Enlarged left atrium. Elevated filling pressures. Symptoms often present. Tissue Doppler essential for diagnosis.

Constrictive pericarditisLow

Pericardial thickening, septal bounce, respiratory variation in mitral inflow ＞ 25%. Prominent hepatic vein reversal. Normal e' velocity (often increased). CT or MRI diagnostic.

Restrictive cardiomyopathyLow

Marked biatrial enlargement, thickened walls (amyloid). Restrictive filling pattern with mitral annular calcification. Granular sparkling appearance on amyloid. Low voltage on ECG with thick walls on echo (amyloid).

Athlete's heart (benign)Moderate

Normal or supranormal diastolic function. Increased LV mass but normal geometry. Normal or enhanced relaxation. No elevation in filling pressures. Reverts with deconditioning.

Management Based on Findings

What Happens Next?

Control blood pressure

Immediate and ongoing

Target BP ＜ 130/80 mmHg. ACE inhibitors or ARBs preferred. May reduce progression. Beta-blockers also beneficial. Regular BP monitoring at home.

Manage comorbidities

Within weeks of diagnosis

Treat coronary artery disease if present. Optimize diabetes control. Weight loss if obese. Treat sleep apnea if present. Reduce alcohol intake.

Diuretic therapy if symptomatic

If volume overloaded

Loop diuretics for volume removal. Thiazides for maintenance. Careful monitoring of kidney function and electrolytes. Goal: euvolemia without dehydration.

Exercise program

After evaluation

Aerobic exercise 150 minutes weekly. Improves diastolic function over time. Cardiac rehabilitation if appropriate. Start low, progress slowly.

Follow-up echocardiography

Every 1-2 years or if clinical change

Monitor progression of diastolic dysfunction. Assess response to treatment. Evaluate for pulmonary hypertension. More frequent if symptomatic.

Frequently Asked Questions

Is diastolic dysfunction the same as heart failure?

Not exactly. Diastolic dysfunction is an abnormality of heart relaxation that can exist without symptoms. When symptoms (dyspnea, edema, fatigue) develop due to diastolic dysfunction, it's called heart failure with preserved ejection fraction (HFpEF). Many people with mild diastolic dysfunction never develop heart failure.

Can diastolic dysfunction be reversed?

Complete reversal is uncommon, but improvement is possible. Grade I diastolic dysfunction may even be considered a normal age-related change. Higher grades can improve with blood pressure control, weight loss, exercise, and appropriate medications. The key is preventing progression rather than expecting complete normalization.

References

  1. American Society of Echocardiography. Guidelines for the Evaluation of Left Ventricular Diastolic Function by Echocardiography. 2023.
  2. European Association of Cardiovascular Imaging. 2022 Recommendations for Diastolic Function Assessment.
  3. Nagueh SF, et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography. J Am Soc Echocardiogr. 2023.

Medical Disclaimer: This information is educational only. Always discuss findings with your healthcare provider for personalized medical advice.

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Diastolic Dysfunction on Echocardiography on ECHOCARDIOGRAPHY: Meaning, Causes & Next Steps