Diastolic Stress Echocardiography in Unexplained Dyspnea: Confirmation of HFpEF
Indications for Diastolic Stress Testing
According to the ASE Update (2025), diastolic stress testing is indicated in patients with dyspnea and Grade I diastolic dysfunction at rest, as well as in those with indeterminate LV filling pressure at rest. For exertional dyspnea of unclear etiology, stress echocardiography is considered the preferred test (ASE, 2020).
Parameters to Assess
According to ASE recommendations (2020), in addition to assessment of regional wall contractility during exercise, the following should be evaluated at rest and during stress:
— tricuspid regurgitation velocity (TR);
— diastolic function (including E/e').
Criteria for Elevated LV Filling Pressure During Exercise
| Parameter | Threshold (BSE, 2024) |
|---|---|
| E/e' | > 14 |
| TR velocity | > 2.8 m/s |
Echocardiographic parameters are considered indicative of diastolic dysfunction with exercise-induced elevation of LVFP when E/e' > 14 and TR velocity > 2.8 m/s (BSE, 2024). The E/e' ratio remains only one of the parameters in the algorithm for assessing LV diastolic function.
Result Interpretation
Interpretation of diastolic stress echocardiography should account for exercise-induced symptoms, hemodynamic factors (heart rate and blood pressure), and patient age (BSE, 2024). Important: regardless of LV diastolic function, SPAP and correspondingly TR velocity may increase at higher heart rates and cardiac output in elderly patients.
Prognostic Value
According to ASE (2025), patients with elevated filling pressure after exercise but without ischemia have a worse prognosis than those with isolated ischemia. Values of PASP > 50 mmHg or TR velocity > 3.2 m/s indicate a worse outcome, justifying this threshold criterion.
When to Proceed to Invasive Evaluation
Invasive hemodynamic assessment, including with stress, may be necessary when results of stress echocardiography are negative or indeterminate in a patient with a clinical presentation suspicious for HFpEF (ASE, 2025).
Frequently asked questions
Which patients are indicated for diastolic stress testing?
Patients with dyspnea and Grade I diastolic dysfunction at rest, as well as those with indeterminate LV filling pressure at rest (ASE, 2025).
What thresholds confirm elevated filling pressure during exercise?
E/e' > 14 and TR velocity > 2.8 m/s (BSE, 2024).
Which parameters should be assessed during exercise besides diastolic function?
Regional wall contractility and tricuspid regurgitation velocity at rest and during stress (ASE, 2020).
What values indicate a worse prognosis?
PASP > 50 mmHg or TR velocity > 3.2 m/s; additionally, patients with elevated filling pressure after exercise without ischemia have a worse prognosis (ASE, 2025).
When should invasive evaluation be pursued?
When stress echocardiography results are negative or indeterminate in a patient with clinical presentation suspicious for HFpEF, invasive hemodynamic assessment, including with stress, may be required (ASE, 2025).