Diastolic dysfunction diagnostic criteria

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Assistant Editor(s)-in-Chief: Rim Halaby


The evaluation of the presence of diastolic dysfunction in patients presenting with symptoms of heart failure is of paramount importance.

The accuracy of clinicians to diagnose diastolic dysfunction has been questioned[1][2].

The diagnosis of diastolic dysfunction or diastolic heart failure is not clinical and requires a work up that goes beyond the history, physical exam, echocardiography and chest X-rays. Several studies have evaluated the diagnostic criteria to follow in differentiating systolic dysfunction from diastolic dysfunction.

Diagnostic Criteria

The diagnostic criteria published by the Working Study Group for the European Society of Cardiology in 1998 included three obligatory conditions for the diagnosis of diastolic heart failure:

Signs or Symptoms of Heart Failure

Normal or Mildly Abnormal Systolic Left Ventricular (LV) Function

  • LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m2

Evidence of Diastolic LV dysfunction

  • IVRT: <30 years > 92 ms; 30–50 years > 100 ms; >50 years > 105 msc
  • E/A<1 + DT>220 ms + S/D<1.5 <50 years
  • E/A<0.5 + DT>280 msec + S/S>2.5 >-50 years[3]

To note that: DT = deceleration time of E velocity, E/A = ratio of early diastolic velocity to atrial velocity, EF = ejection fraction, HF = heart failure, IVRT = isovolumic relaxation time, LV = left ventricular, LVIDDi = left ventricular internal diastolic diameter index, S/D = ratio of systolic to diastolic velocity of venous pulmonary veins.

Other authors have suggested that signs and symptoms of heart failure with a normal ejection fraction is adequate in chronic[4] and acute[5] heart failure.

Determining severity

Echocardiography may grade the severity of diastolic dysfunction, parameters include:[6]

  • Mild:
    • E/A ratio <0.8
    • E/e′ ratio < 8
  • Moderate (grade II; "impaired myocardial relaxation with mild to moderate elevation of LV filling pressures"):
    • E/A ratio 0.8 to 1.5 (pseudonormal)
    • E/e′ (average) ratio is 9 to 12
  • Severe (grade III; "restrictive LV filling occurs"):
    • E/A ratio ≥ 2
    • E/e′ (average) ratio > 13


  1. Caruana L, Petrie MC, Davie AP, McMurray JJ (2000). "Do patients with suspected heart failure and preserved left ventricular systolic function suffer from "diastolic heart failure" or from misdiagnosis? A prospective descriptive study". BMJ. 321 (7255): 215–8. PMC 27439. PMID 10903655.
  2. Banerjee P, Banerjee T, Khand A, Clark AL, Cleland JG (2002). "Diastolic heart failure: neglected or misdiagnosed?". J Am Coll Cardiol. 39 (1): 138–41. PMID 11755299.
  3. European study Group on Diastolic Heart Failure. How to diagnose diastolic heart failure. Eur Heart J 1998;19:990-1003.
  4. Zile MR, Gaasch WH, Carroll JD, Feldman MD, Aurigemma GP, Schaer GL; et al. (2001). "Heart failure with a normal ejection fraction: is measurement of diastolic function necessary to make the diagnosis of diastolic heart failure?". Circulation. 104 (7): 779–82. PMID 11502702.
  5. Gandhi SK, Powers JC, Nomeir AM, Fowle K, Kitzman DW, Rankin KM; et al. (2001). "The pathogenesis of acute pulmonary edema associated with hypertension". N Engl J Med. 344 (1): 17–22. doi:10.1056/NEJM200101043440103. PMID 11136955.
  6. Nagueh SF, Appleton CP, Gillebert TC, Marino PN, Oh JK, Smiseth OA; et al. (2009). "Recommendations for the evaluation of left ventricular diastolic function by echocardiography". J Am Soc Echocardiogr. 22 (2): 107–33. doi:10.1016/j.echo.2008.11.023. PMID 19187853.

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