The 2025 ASE diastolic function algorithm

The 2025 ASE update grades diastolic function and estimates left atrial pressure from three primary variables: annular e′, average E/e′ and peak TR velocity. Supplemental variables break ties. This page walks through it and grades your numbers.

By James Napolitano. Cutoffs from the guidelines cited below.

The three primary variables

Primary variable	Abnormal
Mitral annular e′	Septal ≤6, lateral ≤7 or average ≤6.5 cm/s
E/e′	Average ≥14 (septal ≥15 or lateral ≥13 if only one site)
Peak TR velocity or PASP	≥2.8 m/s or ≥35 mmHg

You need mitral E and A from PW at the leaflet tips, septal and lateral e′ from tissue Doppler (see how to measure E/e′) and peak TR velocity from CW (see how to estimate RVSP).

Live exampleFigure 1. Live apical 4-chamber view with a PW gate. It moves from the mid LV to the mitral annulus, the leaflet tips and the left atrium. Only the leaflet tips give a true peak E. Drag the gate yourself.

The steps

All three normal: normal diastolic function.
All three abnormal: elevated LAP. Grade 2 if E/A is under 2, grade 3 if E/A is 2 or more.
Reduced e′ only, with E/A 0.8 or less: grade 1, normal LAP.
Reduced e′ only with E/A above 0.8, one other variable only, or any two abnormal: check supplemental variables. LA reservoir strain ≤18%, pulmonary vein S/D ≤0.67, LAVi over 34 mL/m² or IVRT ≤70 ms support elevated LAP, then grade by E/A. If none meet the cutoff, LAP is likely normal.¹

Grade your numbers

This calculator uses LAVi as the supplemental variable.

Calculator

Mitral E

cm/s

Mitral A

cm/s

Septal e′

cm/s

Lateral e′

cm/s

Peak TR velocity

m/s

LAVi

mL/m²

When it does not apply

The algorithm is for sinus rhythm. It does not apply in atrial fibrillation, severe primary mitral regurgitation, any mitral stenosis, moderate to severe annular calcification, mitral repair, replacement or transcatheter edge-to-edge repair, heart transplant, noncardiac pulmonary hypertension, constriction or LVAD. The guideline also says it should not be applied in children, normal pregnancy or the intraoperative setting.¹

Notes

Age-adjusted lower limits for e′ can be used instead of the fixed cutoffs.¹
E/A 0.8 or less is an impaired relaxation pattern. E/A 2 or more is a restrictive pattern.

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More guides

References

Nagueh SF, 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.