How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

I read with great interest the updated European Society of Cardiology guidelines on the diagnosis of heart failure with normal LV ejection fraction (HFNEF),1 which represent a big step forward relative to the former guidelines.2 I am convinced that these concise and practical recommendations will set the standard of how to diagnose diastolic heart failure for both routine clinical praxis and future studies on HFNEF. However, regarding the tissue Doppler assessment of left ventricular diastolic dysfunction, I would like to challenge the recommendation that the E/E’ cut-off values are based on … averaged velocities of lateral and septal mitral annulus'.1 The guideline article proposes an E/E' cut-off value of more than 15 for diagnostic evidence of presence and less than 8 for absence of diastolic LV dysfunction. As correctly cited, these cut-off values are derived from a well-designed study of Ommen et al.3 However, Ommen et al. did not recommend to use averaged annular velocities but refer to the septal E/E'ratio which correlated better with mean left ventricular diastolic pressure than ratios calculated with velocities taken from the lateral annulus or averaged over the medial and lateral annulus. Moreover, septal E/E' ratios were easier to obtain and showed a larger area under the ROC curve than ratios taken from the lateral annlus.3 In another paper,4 the same group corroborated and extended its findings by showing that the septal E/E' ratio is a powerful predictor of survival after myocardial infarction. Admittedly, other groups which came to different results in comparing the predictive values of septal and lateral E' values have advocated the use of averaged annular velocities,5,6 but nevertheless the original set of two cut-off values for E/E' (8 and 15), which is currently used in the ESC guidelines stems from Ommen et al. Hence, in the absence of a clear evidence for the superiority of averaged values and for the sake of ease and feasibility particularly in daily routine echocardiography, the recommendation to take averaged E' values should be modified.