Stress Echocardiography for Assessment of Diastolic Function

Abstract

Purpose of review: Diastolic dysfunction is an important, though often underappreciated, cause for exertional dyspnea. Echocardiography enables noninvasive evaluation of diastolic function and filling pressure, but images acquired at rest may be insensitive for detection of exertional abnormalities. This review focuses on stress echocardiography to assess diastolic function, including traditional and novel techniques, with emphasis on specific patient sub-groups in whom this testing may be valuable.

Recent findings: Emerging data informs patient selection for diastolic stress testing. Further, increasing literature provides considerations for performance and interpretation of diastolic metrics relevant to patients with heart failure with preserved ejection fraction, hypertrophic cardiomyopathy, athletes, and those with microvascular coronary dysfunction. Methods, such as speckle-tracking and multi-modality imaging, provide additional and complementary information for non-invasive diastolic assessment. This review serves as a guide to optimally utilize existing and novel techniques of stress echocardiography for diastolic assessment across a broad range of patients.

Keywords: Cardiomyopathy; Diastolic dysfunction; Echocardiography; Heart failure with preserved ejection fraction; Strain; Stress test.

Fig. 1

Stepwise approach to assessment of diastolic function. Stress echocardiography is a critical step in the diagnostic algorithm to evaluate diastolic dysfunction as a cause of exertional dyspnea. Beginning with clinical evaluation and resting echocardiography, stress echocardiography using E/e’ and TR Vmax along with additional resting indices of speckle-tracking LA strain and LV apical untwisting can help clinch the diagnosis for those with intermediate pre-test probability. If needed, invasive evaluation in select populations and cardiac MRI for evaluation of etiology are also key for completing the evaluation. NT-pro BNP = N-terminal pro B-type natriuretic peptide. TR = tricuspid regurgitation. LA = left atrium. LV = left ventricle. MRI = magnetic resonance imaging