Update on the BSE diastolic function guideline

Published 28/02/2024

Mr Shaun Robinson, lead author of the guideline and Vice President of the British Society of Echocardiography, shares more information on this highly anticipated publication.

I know many of you are waiting for the publication of the BSE diastolic function guideline. I assure you, no one is keener than me to finally get this published! I wanted to take this opportunity to update you on why it has not yet been published and provide some rationale for the inclusion of novel parameters.

Since the diastolic guideline was presented at the BSEcho 2023 conference in Wales, the BSE have been provided with access to late-breaking and not yet published data which we were able to analyse for the purpose of investigating the accuracy of the diastolic assessment in patients in atrial fibrillation (AF). Consequently, the AF algorithm presented at conference has been adapted for markedly improved accuracy. Whilst we appreciate the confusion that these conflicting messages may have caused, access to this data has been highly valuable and has ensured that our guidance is not only robust, but also based upon the most up-to-date evidence.

The previous BSE diastolic function guideline (Mathews et al) was published in 2013 and incorporated the routine assessment of trans-mitral E/A ratio, E wave deceleration time and pulmonary vein S/D ratio into the main algorithm guidance. It is now clear that while these parameters may, at times, demonstrate good correlation with LV filling pressures when LV systolic function is impaired, albeit with some limitation, they often exhibit very poor correlation when LV ejection fraction is normal. Furthermore, the 2013 guideline did not recommend the routine assessment of either tricuspid regurgitation (TR) velocity or LA function, both parameters that correlate well with LV diastolic function and filling pressures.

The new guidance for 2024 recognises these limitations and by incorporating supplementary parameters into the diastolic assessment, including LA strain (LAs), it is a significant step forward from the previous recommendations and reflects the far greater evidence base that is available to us now than was when published in 2013. Whilst the inclusion of additional supplementary parameters and the relatively novel measure of LAs are new and likely unfamiliar to some echocardiographers, the standard core-variables of E/e′, TR velocity and LAVi will adequately answer the question of LV diastolic function in the large majority of patients in sinus rhythm; the novel and supplementary parameters will not be required routinely. The writing committee appreciate that in some settings these novel parameters may prove challenging to immediately incorporate into routine clinical practice and wish to reiterate that the guidance has been designed to simplify the assessment of diastolic function, as far as is possible, whilst maximising accuracy and simultaneously minimising the number of ‘indeterminate’ results obtained.

Whilst acknowledging that you have all been waiting patiently for the guideline, and there was a great deal of excitement post BSEcho 2023 about the pending publication, I hope you will agree that it is worth pausing long enough to ensure the very latest data can be included.