ASE 2025 LV Diastolic Function Guidelines

LV diastolic function assessment

ASE 2025 guidelines — interactive clinical decision tool | For clinical use by qualified practitioners only

LAP estimation algorithm (sinus rhythm)

Apply to patients in sinus rhythm. Not for: AF, heart transplant, non-cardiac PH, pericardial constriction, LVAD, severe primary MR, any MS, or moderate/severe MAC.

Step 1 — Mitral annular e' velocity

Septal e' (cm/s)

Lateral e' (cm/s)

Patient age (years)

Diastolic dysfunction diagnosis (Figure 2)

Diagnosis requires: an index of LV relaxation (e') + markers of LA/LV remodeling and elevated LAP.

Step 1 — LV relaxation (e' velocity)

Septal e' (cm/s)

Lateral e' (cm/s)

Average e' (cm/s)

Step 2 — LAP/remodeling markers

Average E/e' ratio

LARS (%)

E/A ratio

LAVi (mL/m²)

LV mass index (g/m²)

Sex

Special population assessment

Select population

Atrial fibrillation — LAP estimation

Use average values from several representative cardiac cycles at the average heart rate.

Mitral E velocity (cm/s)

Septal E/e' ratio

TR velocity (m/s)

Deceleration time (ms)

LARS (%)

PV S/D ratio

BMI (kg/m²)

Moderate/severe MAC — LAP estimation (Figure 4)

Mitral E/A ratio

IVRT (ms) — if E/A 0.8–1.8

Pulmonary hypertension — LAP estimation (Figure 6)

Use lateral E/e' (not average) in PH — septal flattening may affect septal velocities.

Mitral E/A ratio

Mitral E velocity (cm/s)

Lateral E/e' ratio

LARS (%)

Restrictive cardiomyopathy — severity grading

E/A ratio

E deceleration time (ms)

IVRT (ms)

Average e' (cm/s)

Average E/e' ratio

HCM — diastolic function assessment

Average E/e' ratio

Ar–A duration (ms)

Peak TR velocity (m/s)

LAVi (mL/m²)

Constriction vs. restriction differentiation (Figure 7)

Respirophasic ventricular septal motion + dilated IVC Septal e' > 8 cm/s (measured below) Annulus reversus (medial e' > lateral e') Hepatic vein end-diastolic reversal/forward ≥ 0.8 Mitral inflow respiratory variation > 25%

Septal e' velocity (cm/s)

Heart transplant recipients — LAP estimation (Figure 5)

Average E/e' ratio

E/SR_IVR ratio (cm) — if E/e' 7–14

TR velocity (m/s) — if SRIVR unavailable

Mitral regurgitation — filling pressure markers

LVEF

IVRT (ms)

Ar–A duration (ms)

IVRT/TE-e' ratio

Average E/e' (reduced EF only)

HFpEF diagnosis — stepwise algorithm (Figure 9)

Requires: symptoms/signs of HF + LVEF ≥ 50% + exclusion of other cardiac/non-cardiac causes.

Clinical prerequisites

Symptoms and/or signs of congestive HF (dyspnea, fatigue, edema) LVEF ≥ 50% confirmed on echocardiogram Significant valvular disease, non-cardiac PH, significant CAD, HCM, amyloidosis, pericardial constriction excluded

Echocardiographic findings

Average E/e' ratio

LARS (%)

E/A ratio

LAVi (mL/m²)

Septal e' (cm/s)

Lateral e' (cm/s)

Peak TR velocity (m/s)

Natriuretic peptides

NP level

H2FPEF score calculator

Validated score (0–9) for patients with unexplained dyspnea. Developed from invasive exercise hemodynamic testing in 414 patients (Reddy et al., Circulation 2018).

Heavy — BMI > 30 kg/m² 2 pts Hypertensive — 2 or more antihypertensive medications 1 pt Atrial fibrillation (paroxysmal or persistent) 3 pts Pulmonary HTN — PASP > 35 mmHg on echo 1 pt Elder — age > 60 years 1 pt Filling pressure — septal E/e' > 9 1 pt

H2FPEF score (out of 9)

Score 0 — Low probability

H2FPEF score 0–1: HFpEF unlikely. Consider non-cardiac causes of dyspnea.

Normal reference ranges by age (Table 5)

Fifth–95th percentile limits from population-based studies in subjects free of cardiovascular disease or risk factors. Normal ranges are not necessarily equivalent to "optimal" values.

Age group

Mitral annular e' cutoffs for impaired LV relaxation (Table 6)

Age	Septal e' (cm/s)	Lateral e' (cm/s)	Average e' (cm/s)
20–39 y	< 7	< 10	< 9
40–65 y	< 6	< 8	< 7
> 65 y	< 6	< 7	< 6.5

Invasive criteria for diastolic dysfunction / HFpEF (Table 1)

Parameter	Abnormal value
Time constant of LV relaxation (τ), ms	> 48
LV chamber stiffness constant	> 0.015
Rest mean PCWP, mmHg	> 15
Rest LVEDP, mmHg	> 16
Exercise mean PCWP, mmHg	≥ 25
Exercise LVEDP, mmHg	≥ 23
PCWP/CO slope during supine exercise, mmHg·L⁻¹·min	> 2

Based on: Nagueh et al. ASE 2025 guidelines, J Am Soc Echocardiogr 2025;38:537–69. For clinical use by qualified practitioners only. Not a substitute for professional medical judgment.

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