LV RV Focused

A Harkness, L Ring et al.
Reference limits for 7:1 G1–G18

echocardiography
GUIDELINES AND RECOMMENDATIONS
Normal reference intervals for cardiac

dimensions and function for use in
echocardiographic practice: a guideline from
the British Society of Echocardiography
Allan Harkness MSc1,*, Liam Ring MBBS2,*, Daniel X Augustine MD3,†, David Oxborough PhD4, Shaun Robinson MSc5
and Vishal Sharma MD6,† on behalf of the Education Committee of the British Society of Echocardiography
1East Suffolk and North Essex NHS Foundation Trust, Essex, UK
2West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
3Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
4Liverpool John Moores University, Research Institute for Sports and Exercise Science, Liverpool, UK
5North West Anglia NHS Foundation Trust, Peterborough, UK
6Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK
Correspondence should be addressed to L Ring: liamring@doctors.org.uk
*(A Harkness and L Ring contributed equally to this work)
†(D X Augustine and V Sharma are the Guidelines Chairs)
D Oxborough and V Sharma are members of the editorial board of Echo Research and Practice. They were not involved in the review or editorial
process for this paper, on which they are listed as authors.
Abstract
This guideline presents reference limits for use in echocardiographic practice, updating Key Words
previous guidance from the British Society of Echocardiography. The rationale for change ff 2D echocardiography
is discussed, in addition to how the reference intervals were defined and the current ff guidelines
limitations to their use. The importance of interpretation of echocardiographic parameters ff reference ranges
within the clinical context is explored, as is grading of abnormality. Each of the following
echo parameters are discussed and updated in turn: left ventricular linear dimensions and
LV mass; left ventricular volumes; left ventricular ejection fraction; left atrial size; right heart
parameters; aortic dimensions; and tissue Doppler imaging. There are several important
conceptual changes to the assessment of the heart’s structure and function within this
guideline. New terminology for left ventricular function and left atrial size are introduced.
The British Society of Echocardiography has advocated a new approach to the assessment
of the aortic root, the right heart, and clarified the optimal methodology for assessment of
LA size. The British Society of Echocardiography has emphasized a preference to use, where
feasible, indexed measures over absolute values for any chamber size.
https://erp.bioscientifica.com © 2020 The British Society of Echocardiography This work is licensed under a Creative Commons
https://doi.org/10.1530/ERP-19-0050 Published by Bioscientifica Ltd Attribution-NonCommercial-NoDerivatives 4.0
International License.
A Harkness, L Ring et al. Reference limits for 7:1 G2
echocardiography
Introduction Table 1 Echocardiographic parameters covered by the BSE

2019 guidelines.
The British Society of Echocardiography (BSE) has BSE reference intervals 2019
previously provided reference values and guidelines for
Linear left ventricular dimensions and LV mass
chamber quantification through the provision of posters, Left ventricular volumes
pocket guides and the EchoCalc app (1, 2). These were Left ventricular ejection fraction
based on joint publications by the American Society of Left atrial volume
Indexed right ventricular end diastolic area
Echocardiography (ASE) and the European Association
Indexed/non-indexed right atrial area
of Cardiovascular Imaging (EACVI), originally published Right ventricle and right ventricular outflow tract diameter
in 2005 (3). Newer right heart data were derived from Right ventricular fractional area change
guidelines published in 2010 (4). The ASE and EACVI Aortic root dimensions
Tissue Doppler: mitral annular s′ and right ventricular s′
subsequently updated their guidelines in 2015 (5, 6).
Since that time further research has been published, using
prospective data collection, on which the BSE has chosen changes suggested within this document are rationalised
to base the current recommendations upon. and that patient care is not adversely affected.
For the current guidance, the BSE has chosen, in
some instances, to deviate from the combined European
and American guidance for our own reference intervals. Methods
There were several reasons for this. Principally, the BSE
Source data
wanted to ensure that the reference ranges were derived
from the most contemporaneous and prospectively A reference interval for any echocardiographic parameter
acquired data; that reference ranges were derived from should be derived from a population of apparently normal
evidence that best applies to the British population; and individuals: that is to say, a group of individuals who are
finally ensure that echo guidance and cut-offs reflect devoid of overt cardiovascular disease. It is preferred if
practice within the UK. This document will outline the individuals with multiple risk factors for cardiovascular
approach taken by the BSE in producing the up-to-date disease (for example, a history of smoking or strong
British guidelines, in addition to detailed explanatory family history of coronary disease) are excluded as they
notes regarding each parameter in turn. Reference may have as yet undiagnosed cardiac abnormalities that
intervals for the parameters in Table 1 are described in could influence the results. Once the population has
the main document and summarised in Supplementary been defined, adequate numbers of ‘normal’ participants
Table 1 (see section on supplementary materials given across the spectrum of ages and body sizes are needed
at the end of this article). Diastolic parameters will be to ensure that the reference limits can be considered
covered in a separate guideline. representative of the population at large. Studies ideally
The overarching objectives of this document were to: should be prospectively recruited and not identified from
retrospective review of echo databases. There should be
1. Provide a simple, practical reference document and
clear echo protocols such that each parameter is obtained
guide for everyday use by our members.
using optimized views and best practice. In the perfect
2. Enable appropriate interpretation of values into a
scenario, echo images would be reported in a core-lab, or
clinically relevant report.
dedicated independent echo-lab, to guarantee that the
3. Encourage the holistic interpretation of measurements –
analysis of images and therefore the results are consistent.
no single number should define normality or pathology.
Finally, the individuals included in the reference data
The BSE acknowledges that the changes suggested within should reflect the population to which the ranges will
this document may result in some individuals who were then be applied.
previously labelled as having an echocardiographic The ASE/EACVI guidance from 2015 extracted echo
abnormality now being considered as normal (and vice data from several large databases to derive reference
versa). Although this can present a challenge to clinicians, intervals (5, 6). This was commendable as it maximizes
the changes are necessary and are reflective of the current the number of participants, but for some parameters
evidence-base. The BSE advocates that echo departments results in suboptimal methodology: for example, left
discuss the new reference limits with end-users, including ventricular ejection fraction (LVEF) from the apical
cardiologists and other clinicians, to ensure that the four-chamber view was obtained from more than 2000
echocardiography
individuals, but the biplane LVEF intervals were derived reference intervals. The results from the EchoNormal
from around 500 patients. In addition, including data project provide a valuable insight into ethnic variation,
from multiple sources means that the echocardiographic and age-dependent changes of echo parameters. It is
methods for all subjects were not necessarily uniform, commendable that the cohort used in EchoNormal was
nor was quality assured with the use of a dedicated large. However, the meta-analysis design means that the
independent echo-lab. Finally, some results were obtained inclusion criteria for each of the 43 studies included were
from a North American population and therefore may not not necessarily identical, and the definition of ‘normal’
be completely applicable to the British population. was not uniform. Echo images were analysed in the
Two major studies presenting useful individual centres, and therefore consistency could not be
echocardiographic reference intervals have been guaranteed. For some parameters (including ventricular
published subsequent to the joint ASE/EACVI guidance. volumes and LVEF), data from one or more centres were
The first of these was the Normal Reference Ranges for excluded as it appeared to deviate significantly from the
Echocardiography (NORRE) dataset which has resulted results seen elsewhere, which raises questions regarding
in multiple publications (7, 8, 9, 10). The NORRE project validity. Finally, a large proportion of the participants
included over 700 individuals, and the study design and were not European, and therefore the relevance to a UK
execution fulfil many of the ideal criteria outlined above. population is less clear.
Participants were prospectively recruited, with pre- For these reasons, the current BSE reference intervals
defined echo protocols. All echo data were analysed by were in large part derived from the NORRE dataset.
a core-lab, ensuring consistency of results. The included
individuals were free from both overt cardiovascular
Defining reference intervals
disease and had low clinical probability of latent disease,
were not taking any cardio-active medication, and all This guideline proposes reference intervals for
had lab testing for hyperglycaemia, dyslipidaemia, echocardiography. These are not the same as ‘normal
and renal function. Competitive athletes and obese ranges’, and it is of paramount importance to understand
individuals were excluded. Care was taken to ensure that the difference as this necessarily affects the way in which
sufficient numbers of individuals from all age categories the ranges produced within this document are applied in
were included. This study was a European collaborative day-to-day practice.
project and therefore the results can be considered Statistical convention used throughout the literature
applicable to the UK population (7). states that a reference interval includes 95% of the
The second study was the EchoNormal project, a normal population (Fig. 1). By definition, this excludes
large meta-analysis of more than 50,000 individuals of the remaining ‘normal 5%’ who appear at the upper and
differing ethnicities, obtained from over 40 different lower extreme. If the parameter in question is normally
studies undertaken worldwide (11). After exclusions, distributed, the 95% reference intervals can be obtained
more than 22,000 participants were used to define from the data using the mean ± 1.96 × standard deviation.
Figure 1
The normal distribution curve. Using a
combination of the population mean and
standard deviation, reference limits can be
calculated. A range of values encompassing 2
standard deviations above and below the
population mean includes 96.4% of all ‘normal’
subjects. Similarly, 3 standard deviations
encompass 99.7% of the normal population.
echocardiography
However, for almost a century, 1.96 has been rounded to or it may provide information as to prognosis for a particular
2, which covers 95.4% of the population (12). Thus: disease. To a clinician, an abnormality labelled as ‘severe’
will usually demand attention and probably treatment (i.e.
Upper reference limit (URL) = mean value +
it should not be ignored).
(2 × standard deviation)
The partition between a ‘mild and moderate’, or
Lower reference limit (LRL) = mean value – ‘moderate and severe’ abnormality can be defined in
(2 × standard deviation) a number of ways. Perhaps the ideal method would be
to define the severity of the abnormality according to
It is a frequent misconception that if an individual parameter
prognostic significance: progression from mild to moderate
falls outside of the reference limits it should always be
to severe abnormality would be associated with clear
considered as abnormal. If we take the example of left
impact on cardiovascular outcomes from contemporary
ventricular (LV) dimensions: using the above methodology,
studies. In reality, however, most echocardiographic
it is expected that 4.6% of all normal patients will have
parameters such as LVEF or LA size display a continuous
values that are either above the upper reference limit or
association with survival (i.e. as the LVEF gets progressively
below the lower reference limit. In clinical practice, more
lower, survival is progressively poorer (13)), and specific
importance is often applied to one extreme: practitioners
cut-offs are defined more for clinical simplicity and utility
may consider an increased LV size as clinically more relevant
as opposed to being genuinely disease defining. A different
than a reduced size. Even in this scenario, a substantial
methodology would be to define partitions according to
number of individuals (2.3% of ‘normal’ patients) will
clinical intervention(s) available at specific points.
have LV dimensions that are above the URL. It is therefore
Another frequent practice is to define these partitions
essential to interpret any value that falls outside of the
as a function of the standard deviation and the mean.
reference limits within the clinical context, rather than
Just as the upper reference limit is usually two standard
immediately consider them as abnormal.
deviations above the mean, the partition between mild
Similarly, it is also possible for a parameter to fall
and moderate abnormality is defined as three standard
within the reference interval, and yet, it may not actually
deviations above the mean, and the moderate/severe
be ‘normal’ for that individual. For example, a patient may
threshold as four standard deviations above the mean. This
be noted to have an LVEF result that drops from 65 to 55%
is akin to paediatric cardiologist’s use of Z-scores, where
on sequential measurements. Although both of these LVEF
the Z-score is the number of standard deviations from the
values are within the ‘normal reference limit’, in this case,
mean (14). Although superficially this approach may not
it is quite possible that there is an underlying pathological
appear to have clinical relevance, it has value in providing
process and incipient LV systolic dysfunction. It is therefore
information as to how frequently this magnitude of
of paramount importance that echocardiographic values,
variation would be expected within a normal population.
whether they are superficially normal or not, are always
Taking the example of LV dimensions: just as 2.3% of
interpreted in the clinical context. If a patient has had
normal individuals will have an LV size above the upper
previous echo studies, comparison between historical and
reference limit, a tiny proportion of normal individuals
contemporary findings is of significant clinical utility.
(just 0.15% of the normal population) would have
The above statistical methodology has been applied
values in the ‘moderate’ range using this methodology.
to the NORRE data to derive reference limits for most
Furthermore, essentially no normal patients would ever
echocardiographic parameters. Detailed explanations are
be expected to have LV dimensions in the ‘severe’ range
provided where the BSE has deviated from this practice.
(Fig. 1). This further re-iterates the clinical approach that
once an individual parameter is close to severely abnormal
Grading of abnormality
immediate clinical attention is warranted.
Once an echocardiographic value falls outside of the reference Within these guidelines, grading ranges have been
intervals, it is common practice to consider the parameter in provided only where they have clinical utility.
question as being ‘mildly, moderately or severely’ abnormal
(bearing in mind that, as discussed above, the normal/mildly
Normal variation
abnormal zone will have some overlap). There are several
reasons why this approach is useful: it helps to give an idea Many, if not all, echocardiographic parameters vary
as to the magnitude of abnormality to the referring clinician, according to gender, body habitus (either height, weight
it may provide use in monitoring of disease progression, or both), ethnicity, fitness, and age. If all these variables
echocardiography
were factored into every single measurement, reporting the tables will not be as reliable in individuals of different
times would become unreasonable, and the associated ethnic origin (7). For example, there is some evidence that
reference tables would be unwieldy. We have attempted individuals of Afro-Caribbean or Asian descent differ from
to include as many useful variables as is practical, whilst Caucasian counterparts with regards LV mass values (11).
maintaining the simplicity for busy echo practitioners. The BSE has chosen not to include ethnicity-specific
However, this has necessarily led to some compromises. reference intervals for several reasons. Firstly, as we
One compromise is regarding age-related variations. discussed earlier, currently available ethnicity-specific
Several echocardiographic criteria (for example left and data from EchoNormal is not as robust as NORRE. As yet
right ventricular size and LVEF) vary with normal aging, unpublished data from the upcoming World Alliance
whereas others (including left and right atrial volumes of Societies of Echocardiography Normal Values Study
and LV mass) do not (8). The BSE believes that it would be (WASE trial, presented in abstract form) suggests that in
impractical to divide reference tables to account for this addition to ethnicity, the country in which an individual
variation in some but not all parameters, particularly if lives results in important echocardiographic variation.
the absolute difference is often so small as to be clinically For example, individuals of Chinese descent differ
insignificant. This compromise approach re-iterates the considerably if they live in China compared to those
need to interpret values that are slightly outside the that live in Europe. Similar inter-country variation was
reference limits with caution, particularly if they are seen with all ethnicities. This further reinforces the BSE’s
obtained in patients at the extremes of age. belief that using data obtained from China or Asia to
Echocardiographic parameters are usually indexed derive reference intervals for individuals living in the
according to BSA. For certain parameters, such as left UK would not be valid. Secondly, an ethnic-specific
atrial (LA) volumes, there is a wealth of evidence that approach would necessarily require all sonographers to
this approach is reasonable (15, 16). For others, this ask for a patient’s ethnic origin prior to undertaking an
approach may not be as useful. For example, although echo exam, which could be considered unreasonable.
the NORRE dataset published indexed values for internal Thirdly, it is likely that individuals of mixed heritage
LV dimensions and LA diameter, neither of these are would not fit solely into one dataset or another, which
routinely used in clinical practice. The absolute LV would introduce further difficulties when asking patients
internal diameter is a predictor of outcomes in mitral and regarding their ethnicity and subsequently interpreting
aortic valve disease and is used to guide timing of surgical the echo findings.
intervention (17, 18, 19). There is less data to support Therefore, the BSE proposes that the presented
the use of indexed values in this regard. Therefore, the reference tables are used for patients of all ethnicities but
BSE has chosen to publish indexed values only for those reminds sonographers to be aware of potential variation
parameters where there is a clear clinical indication for secondary to ethnicity. Although the available data are not
this approach. sufficient to derive specific reference limits, the following
In obese patients, caution is advised when could be considered within the clinical context:
interpreting indexed values, particularly as the NORRE
database excluded individuals with a BMI >30 kg/m2. The •• Individuals of Afro-Caribbean descent appear to be
metabolic demand of fatty tissue is considerably lower very similar to Caucasians with regards LV volumes
than muscle, and therefore, obesity is less likely to drive and function. LV mass, however, may be marginally
changes in chamber size or wall thickness. In essence, higher, and therefore a ‘mild’ increase in LV mass
indexing for body surface area (BSA) when individuals are should be interpreted with caution and within the
very overweight may result in an underestimation of the clinical context.
degree of cardiac remodelling (20). •• Individuals of East Asian or Indian origin may have
a tendency towards slightly smaller LV volumes. As
such it is possible that LV volumes approaching the
Limitations
proposed upper reference limits may in fact be slightly
There are three patient cohorts in whom these reference abnormal for such ethnic groups and should be
tables may not be applicable. These are non-Caucasian interpreted within the clinical context.
individuals, athletes, and pregnant patients. •• There are insufficient data to provide advice regarding
The NORRE dataset included healthy Caucasian the effects of ethnicity on LA volume or right heart size
volunteers only, and therefore, the values provided in at this time.
echocardiography
Echocardiography in athletes should also be interpreted BSE reference intervals

with caution. Participation in competitive sport results in
remodelling and morphological alterations of the heart, The following section outlines the new BSE reference
including increases in: LV dimensions and volumes, right limits for left and right heart parameters, combined
ventricular (RV) dimensions, LV mass, and LA volumes with explanations of the methodology, decision-making
(21, 22, 23, 24). The magnitude of these morphological process, and discussions regarding the potential clinical
alterations appears to be linked to both the volume and impact of the new reference intervals. Where appropriate,
type of exercise undertaken. There is no practical or widely we have described the methodology by which some of
accepted way in which the effects of exercise on cardiac the measurements should be acquired, but for a more
structure can be readily standardized or accounted for. detailed description regarding the echocardiographic
NORRE actively excluded individuals who participated measurements and how they should be obtained, please
in competitive sport. For this reason, sonographers and see the BSE minimum dataset (28).
clinicians should be cognizant of these potential influences
when interpreting the echocardiographic findings of such
Left ventricular linear dimensions and LV mass
individuals (23).
Finally, caution is advised when using these reference New reference intervals for linear LV dimensions and
tables to interpret echocardiographic studies in pregnant LV mass are presented in Table 2. LV dimensions should
women. Physiological cardiac adaptation during be obtained from the parasternal long-axis (PLAX)
pregnancy includes enlargement of the left and right window preferentially using 2D imaging. The BSE would
ventricles and the atria, in addition to changes in left and discourage the use of M-mode measurements as routine,
right ventricular function (25). NORRE excluded pregnant although they are acceptable if the long-axis of the left
individuals from the study. ventricle is perpendicular to the angle of incidence of
the ultrasound beam. LV mass should be calculated using
the linear method from 2D imaging and reported after
Timing
indexing to BSA (8).
Timing of measurements is critical. ECG timings can vary The BSE has chosen to publish an upper reference
with the lead used and is affected by conduction defects limit only for wall thickness measures with no separate
and coronary artery disease (26). The 2015 chamber
guidelines and many textbooks have varying definitions Table 2 Linear left ventricular dimensions and mass.
(5, 6). The definitions from the EACVI/ASE/Industry Task
Normal Mild Moderate Severe
Force paper on standardising deformation imaging have
Males
thus been adopted as follows (27).
LV dimensions
LVIDd (mm) 37–56 57–61 61–65 >65
Ventricular end systole LVIDs (mm) 22–41 41–45 46–50 >50
The timing of ventricular end systole is taken as the frame IVSd (mm) 6–12 – – –
LVPWd (mm) 6–12 – – –
where the aortic valve initially closes. This coincides with
LV mass
a closure click on the pulsed-wave Doppler tracing of LVMi (g/m2) 40–110 111–127 128–145 >145
aortic valve flow. When obtaining images from the apical LV mass (g) 72–219 – – –
2- or 4-chamber views, end-systole is defined as the frame Females
LV dimension
prior to mitral valve opening (5, 6). In addition, this is
LVIDd (mm) 35–51 52–55 56–59 >59
the point at which maximal volume of the LA should be LVIDs (mm) 20–37 38–42 43–46 >46
obtained. IVSd (mm) 5–11 – – –
LVPWd (mm) 6–12 – – –
LV mass
Ventricular end diastole
LVMi (g/m2) 33–99 98–115 116–131 >131
The timing of ventricular end diastole is taken as the LV mass (g) 51–173 – – –
frame before the mitral valve closes. Surrogates for this
IVSd, inter-ventricular septal thickness in diastole; LV, mass calculated using
are the frame with the largest LV cavity size (diameter or
the linear method; LVIDd, left ventricular internal diameter in diastole; LVIDs,
volume), the start of the ECG QRS complex, or the ECG left ventricular internal diameter in systole; LVMi, left ventricular mass index;
R-wave (a common trigger for analysis software). LVPWd, left ventricular posterior wall thickness in diastole.
echocardiography
partitions for mild, moderate, or severe changes, as using the pattern of LVH is ‘eccentric’. The pattern of LVH
standard deviations to define partitions would result provides an insight into the underlying pathophysiological
in such narrow ranges that they would be clinically state. Concentric LVH is characteristically seen in
meaningless. patients with increased afterload such as aortic stenosis
LV wall thickness by itself does not define an individual or hypertension. Eccentric LVH is more likely to be seen
as having left ventricular hypertrophy (LVH). Rather, the in scenarios with increased LV pre-load and associated
presence or absence of LVH is determined from LV mass compensatory hypertrophy, such as chronic aortic
after indexing to BSA. Wall thickness measurements, regurgitation (AR) or mitral regurgitation (MR).
combined with the LV internal diameter in diastole, can A common misconception is that concentric LVH is
be used to determine the relative wall thickness (RWT) synonymous with uniform thickening of the myocardial
using the following formula: walls. It is possible to have localised or focal areas of
increased wall thickness in patients with concentric LVH,
IVSd + LVPWd just as there may be uniform thickening of muscle in
RWT =
LVIDd patients with eccentric LVH.
The combination of indexed LV mass and relative wall If LV mass is normal (i.e. the patient does not have
thickness can be used to define LV geometry (Fig. 2). In the LVH), an RWT > 0.42 demonstrates the presence of
context of an increased mass, an RWT > 0.42 defines the ‘concentric remodelling’. This can be thought of as a pre-
pattern of LVH as being ‘concentric’. If the RWT is ≤0.42, hypertrophy state and may help to identify individuals
who would benefit from identification and optimization
of risk factors (i.e. hypertension) (6).
Left ventricular volumes
Reference intervals for LV volumes are presented in

Table 3. Left ventricular volumes should be obtained using
2D imaging from the apical 4- and 2-chamber windows
using the biplane Simpson’s method. When obtaining LV
volumes using the biplane method, care should be taken
to ensure that the apical 4- and 2-chamber windows are
separated by 60° of rotation (and not 90° as is sometimes
assumed). In addition, it is paramount that the LV is not
foreshortened. Volumes should be reported after indexing
to BSA.
Table 3 Left ventricular volumes.
Mildly Moderately Severely

Normal dilated dilated dilated
Males
LVEDVi (mL/m2) 30–79 80–91 92–103 >103
LVESVi (mL/m2) 9–31 32–36 37–42 >42
LVEDV (mL) 53–156 – – –
LVESV (mL) 15–62 – – –
Females
LVEDVi (mL/m2) 29–70 71–81 82–91 >91
LVESVi (mL/m2) 8–27 28–32 33–37 >37
LVEDV (mL) 46–121 – – –
LVESV (mL) 13–47 – – –
Volumes obtained using the biplane Simpson’s method.

Figure 2 LVEDV(i), left ventricular end-diastolic volume (indexed); LVESV(i), left
LV geometry determined by indexed LV mass and relative wall thickness. ventricular end-systolic volume (indexed).
echocardiography
Left ventricular ejection fraction Table 4 Left ventricular ejection fraction.
Summary Severely
impaired Impaired Borderline Normal
•• Reference intervals for LVEF are the same for males and LVEF LVEF low LVEF LVEF
females (Table 4). Males and females

•• LVEF should be derived from 2D volume data using the LVEF (%) ≤35% 36–49% 50–54% ≥55%
biplane Simpson’s method.
LVEF derived using the biplane Simpson’s method.
•• Normal LVEF is defined as an EF ≥55%.
•• Patients with an LVEF between 50 and 54% are defined The rationale for the BSE decision is one of clinical
as having ‘borderline low LVEF’. utility. There is a large body of evidence demonstrating
•• Patients with an LVEF between 36 and 49% are defined that therapeutic drugs used in the management of left
as having ‘impaired LVEF’. The BSE discourages use of ventricular systolic dysfunction are of prognostic value
the terms ‘mild’ or ‘moderate’. when LVEF is ≤35%. This includes ACE-inhibitors,
•• These reference intervals do not apply to values of LVEF B-blockers, mineralocorticoid receptor antagonists,
obtained using 3D imaging. If EF is obtained using 3D angiotensin receptor antagonists, If-channel inhibitors,
imaging, these should be compared to vendor-specific and angiotensin receptor-neprilysin inhibitors (29,
reference intervals. 30, 31, 32, 33, 34, 35, 36, 37, 38). Furthermore, in UK
practice, device therapy for heart failure, including CRT
Rationale and discussion and ICD, are also indicated when the LVEF is 35% or
LVEF should be derived using the biplane Simpson’s below (38, 39, 40, 41). Although it is true to state that
method from 2D volumes, obtained from the apical 4- a lower ejection fraction is associated with a poorer
and 2-chamber views as described above. It is essential prognosis (13), there are no additional therapeutic
that values for LVEF are not derived from foreshortened interventions either mandated or available only after
or poorly obtained volumetric data. The BSE has chosen LVEF falls below 30%. For these reasons, in the opinion of
to keep reference intervals the same for males and females the BSE, the most useful threshold for severely impaired
(Table 4). LVEF is ≤35% as this provides clarity for clinicians and
Within the NORRE dataset, there was a statistically sonographers alike.
significant difference between males and females with A change is also advocated for LVEF values between 35
regards to ejection fraction values (8). For males, the lower and 55%. The BSE has chosen to depart from the tradition
reference limit was 53.5%, whereas for females, the value of splitting this group into ‘mild’ or ‘moderate’ bands and
was 54.5%. The P value for the difference between men have defined individuals with an EF between 50 and 54%
and women was 0.009. Despite the statistical difference as ‘borderline low LVEF’, and those patients with values
between genders, the absolute difference is so small as between 36 and 49% as ‘impaired LVEF’. The rationale for
to be clinically insignificant. It would be very unusual this approach is as follows.
to report echocardiographic-derived EF values with As outlined in the ‘defining reference limits’ section,
a purported accuracy of 1%: accepted inter-operator the method by which the LRL for LVEF is calculated
variability of LVEF measurements are often in the order means that 2.3% of normal individuals will fall below
of 5%. Additionally, for men and women alike, there was the threshold and may consequently (and incorrectly)
a statistically significant increase in LVEF with aging: for be labelled as having LV systolic impairment. This can
women under 40 years of age, the lower reference limit have important consequences upon that individual:
was 53.9%, whereas for women over 60 years of age, for example, with regards obtaining life insurance, or
this limit was 55.1%. Again, for practical purposes, these impacting career decisions. However, it is also true to state
differences are clinically insignificant. that within this cohort there are patients whose prognosis
Given this, the BSE chose to keep LVEF reference is constrained (42). Too much emphasis has been placed
intervals the same for men and women, with normal LVEF on LVEF as the sole arbiter of normal systolic function.
defined as a value ≥55%. Just as no one parameter defines diastolic function, LVEF
The BSE chose to define ‘severely impaired LVEF’ similarly cannot provide a binary normal/abnormal
as an LVEF ≤35% for both males and females. This is cut off for systolic function. The BSE has therefore
in contrast to the joint ASE/EACVI guidance, which highlighted that patients with an EF between 50 and
classifies ‘severely abnormal LVEF’ as <30% (5, 6). 54% have ‘borderline low LVEF’. The sonographer and
echocardiography
clinician require more information before labelling such With regards 3D volumetric assessment and 3D-derived
a patient as having normal or abnormal systolic function. ejection fraction, the BSE stresses that reference intervals
This is akin to the traffic light system advocated for MRI for 2D-derived ejection fraction do not apply to 3D results:
reference intervals derived from the UK biobank cohort for example, an ejection fraction of 56% derived using 3D
(43). Additional information to help determine whether software is not necessarily normal, and comparison with
a patient is normal may include LV volumes and tissue vendor-specific reference intervals should be used.
Doppler imaging (s′ and e′), prior echo reports, clinical
history, cardiovascular symptoms, family history, and a
Left atrial size
functional assessment. Recommending repeating the
echo after a 6–12-month interval may be required. Summary
Once LVEF falls below 50%, this corresponds to
•• Reference limits for LA volume are the same for males
three standard deviations below the mean. It is therefore
and females.
exceptionally unlikely that a normal individual would
•• LA volume should be obtained from apical 4- and
have an EF below this value (fewer than 0.15% of the
2-chamber windows using the biplane Simpson’s
normal population). As such, those patients with values
method and indexed for BSA.
between 36 and 49% should all be classed as having
•• An LA volume index (LAVi) of <34 mL/m2 is normal.
‘impaired LVEF’ and the ejection fraction quoted. All
•• An LAVi between 34 and 38 mL/m2 is a borderline
patients within the ‘impaired LVEF’ cohort have reduced
result.
left ventricular systolic function and such a finding
•• An LAVi of >38 mL/m2 is abnormal.
should prompt a comprehensive clinical assessment and
•• The area-length (A-L) method should not be used
discussion with the patient.
interchangeably with the Simpson’s method. BSE
An LVEF of 50% has important implications in both
reference intervals for LA volume do not apply to values
heart failure and valvular heart disease management,
obtained using the A-L method.
re-enforcing the use of this threshold as a clinically
•• Routine use of linear LA dimensions is not encouraged,
relevant cut-off. When the LVEF is below 50%, there
but may be used in some clinical scenarios.
remains a reasonable body of evidence that therapeutic
agents may be of value in improving survival (44, 45,
Rationale and discussion
46). Similarly, observational data have suggested that
Reference limits for left atrial size are presented in
cardiovascular survival and outcomes are significantly
Table 5. LA volume should be obtained from apical 4-
poorer once LVEF is lower than 50% (42). A cut-off for
and 2-chamber windows (separated by 60° of rotation),
LVEF of 50% therefore ensures that all individuals who
optimised for LA assessment, using the biplane Simpson’s
may benefit from heart failure therapy are included in
method. Maximal LA volume should be obtained from the
the ‘impaired LVEF’ group. This range is similar to that
frame immediately prior to mitral valve opening. Values
proposed by the European Society of Cardiology who
should be reported after indexing for BSA.
have defined a ‘heart failure with mid-range ejection
Although absolute LA volumes are usually larger in
fraction’ group in whom it is reasonable to consider
males than females, this difference is entirely neutralised
medical therapy whilst accepting that further research
when indexing for BSA. As such, routine assessment of
is required (38, 47). Conversely, even in patients with
indexed LA volumes allows a single reference limit for both
clinical heart failure and LVEF values of >50% (heart
males and females to be utilized (8). Indexed LA volumes
failure with preserved ejection fraction; HFpEF), there is
are linked to adverse prognosis and poor cardiovascular
no evidence to support that routine use of heart failure
outcomes, supporting the routine use of this measure in
medications improves survival (38).
patients (15, 16, 48, 49, 50, 51, 52).
The BSE discourages use of the terms ‘mild’ or
‘moderate’ reduction in LVEF.
Previously, inter-observer variation would often result Table 5 LA volume.
in patients alternating between the mild and moderate
Normal Borderline Dilated
categories without this having any clinical meaning.
The current methodology will hopefully allow more Males and females
LAVi (ml/m2) <34 34–38 >38
consistency with regards reporting within the range of
LVEF between 36 and 49%. LA volume obtained using biplane Simpson’s method.
echocardiography
There were two particularly interesting observations The BSE has chosen to advocate a compromise
reported within the NORRE dataset. Firstly, the NORRE approach that acknowledges the results of NORRE,
investigators examined two widely used but differing but also ensures that an LA volume sufficient for identifying
methods to assess LA volume on all included subjects: patients with diastolic dysfunction is highlighted.
the biplane method of discs (Simpson’s method) and A consensus view was therefore achieved within
the biplane area-length method. Consistent with earlier the writing committee. Using the biplane Simpson’s
comparative studies of these two methods, NORRE method, normal LAVi is ≤34 mL/m2. Values between 34
demonstrated that the area-length technique produces and 38 mL/m2 should be considered ‘borderline’: as an
values for LA volume systematically larger than those isolated finding such a result is normal. In the presence
obtained using the Simpson’s method (8, 53). Given this, of additional indicators for diastolic dysfunction, for
it is evident that these two methodological approaches to example, an elevated E/e′, an LAVi within this range
the assessment of LA volume are not inter-changeable as should be considered a marker of elevated filling pressures.
is often assumed, and different reference limits should be An LAVi of more than 38 mL/m2 is enlarged.
applied to each. Finally, the BSE does not advocate the routine use of
Unfortunately, this observation creates a number linear LA dimensions, although left atrial diameter may
of potential conflicts in echocardiographic practice, as still be used in some clinical scenarios, including risk-
previous guidelines from the ASE, EACVI and BSE have not assessment in hypertrophic cardiomyopathy (56).
differentiated between these two methods. For example,
when assessing for diastolic dysfunction, an LAVi of >34 The right heart
mL/m2 is one marker for the presence of elevated filling
Summary
pressures (54). It is possible, therefore, that an individual
could have an LAVi above this limit if the area-length •• The BSE advocates the routine use of indexed right
method were used, but below this limit if the Simpson’s ventricular end-diastolic (RVED) area, and indexed
method were chosen. RA area.
The second interesting observation from NORRE •• Conventional linear measurements including RV basal
is that LA volumes in the normal population were diameter (RVD1) and right ventricular outflow tract
significantly larger than previous work has suggested, diameter (RVOT) should additionally be obtained in
which appears to conflict with the published association all patients.
between increased LA volumes and poor prognosis. From •• Updated reference limits for linear dimensions are
the NORRE data, the upper reference limit for LAVi using substantially different from previous BSE guidance and
the Simpson’s method is 38 mL/m2 and using the area- contemporary joint ASE/EACVI guidelines.
length method it is 42 mL/m2. For comparison, in previous
observational work of unselected patients, an LAVi of Rationale and discussion
>40 mL/m2 (obtained using the area-length method) is For the first time, the BSE is advocating use of indexed
associated with considerably poorer survival. Even those parameters in the routine assessment of both right
subjects with an LAVi of >34 mL/m2 have significantly ventricular (RV) and right atrial (RA) size. These parameters
worse outcomes (16). are the indexed right ventricular end-diastolic (RVED)
The explanation for this discrepancy is not clear. area (Fig. 3) and the indexed RA area. This proposed
Although it is well recognized that athletes can develop methodology acknowledges that the right heart varies
enlarged atria, the NORRE protocol excluded such according to body habitus and brings echocardiographic
individuals from the study (7, 24, 55). Nor does it seem reporting of right heart size more in keeping with the
likely that undiagnosed diastolic dysfunction is an accepted method of reporting left heart chamber size. These
explanation: the proportion of individuals with an LAVi newer measures should be combined with conventional
of >34 mL/m2 was similar across the age categories. linear assessment in all patients. Conventional measures
Given the robust nature of patient inclusion and echo include the RV outflow tract (RVOT) dimensions, obtained
analysis, the NORRE results are compelling and strongly from the parasternal short axis (PSAX) window (Fig. 4), and
suggest that the range of normality for LA volume is larger RV body dimensions (Fig. 5), which should be obtained
than previously thought. The results also suggest that from the RV-focussed view. Remember that the RV-focussed
there is a substantial overlap between physiological and view is not necessarily the same as the standard 4-chamber
pathophysiological LA remodelling. view, but is adjusted such that the diameter of the RV is
echocardiography
Figure 3
Assessment of RV size and fractional area change
(FAC). From the RV-focussed apical 4-chamber
window, a contour should be traced from the
lateral tricuspid annulus along the free wall to the
apex, and back along the interventricular septum
to the medial tricuspid valve annulus. This should
be undertaken at end-diastole (left panel), and the
area indexed to BSA, providing us with indexed
RV end-diastolic area. This process can be
repeated in end-systole (right panel), from which
we can derive the FAC as follows: FAC = (RVA
diastole − RVA systole)/RVA diastole × 100%.
maximised, whilst keeping the imaging plane through the (for example, the outflow tract), whereas the main body
centre of the LV cavity (4). of the RV may be normal. To account for this complexity,
Reference limits for right heart measurements and the BSE suggests that indexed RVED area is combined
fractional area change (FAC) are presented in Table 6. with basal RV dimensions and an assessment of RVOT size
The anatomy of the right heart, and RV in particular, in all patients.
is complex. All three components of the RV cannot be The BSE accepts that routine indexing of right heart
visualised from a single echocardiographic plane and parameters is not yet widespread, and indeed these
therefore it is imperative that sonographers do not rely measurements are not included within the BSE minimum
on a single measure to define the presence or absence dataset (28). However, indexed parameters account for
of RV enlargement. Moreover, in some patients there both gender and body habitus and are physiologically
can be relative enlargement of one RV component more robust. The NORRE study obtained indexed right
Figure 5
Figure 4 RV body measurements. All measurements should be obtained at
RVOT assessment (RVOT1). From the PSAX window, and in end-diastole, end-diastole in the RV-focused apical 4-chamber view. RVD1: Basal RV
measurement should be made from the anterior aortic wall directly up to diameter. Measured at the maximal transverse diameter in the basal one
the RVOT free wall (at the level of the aortic valve). The PSAX view is more third of the RV. RVD2: Mid RV diameter measured at the level of the LV
reproducible than RVOT PLAX. papillary muscles. RVD3: RV length, from the plane of the tricuspid
annulus to the RV apex.
echocardiography
Table 6 Right heart parameters. European guidance derived most right heart dimensions
from fewer than 700 subjects (5, 6). The NORRE dataset
Normal
by itself includes more than 700 individuals, in addition
Males
Indexed values to having the benefits of consistency of inclusion and
RVED area (cm2/m2) ≤13.6 analysis outlined previously. Furthermore, the ASE/
RA area (cm2/m2) ≤11 EACVI upper reference limit for RV size is universal (i.e.
Absolute values
the same for both males and females), thereby suggesting
RVOT proximal (mm) 24–44
RVOT distal (mm) 16–29 that gender (and by inference, BSA) does not influence
RVD1 (mm) 26–47 RV size, which seems fundamentally unlikely. The 2010
RVD2 (mm) 19–42 ASE guidance published a range of potential values for
RVD3 (mm) 55–87
the upper reference limit, acknowledging that there is a
RA area (cm2) ≤22
Right heart function degree of uncertainty in any statistical modelling (4). This
FAC (%) ≥30 range was 39–45 mm, and 41 mm was the mid-point of
Females this range. Using NORRE the combined URL for men and
Indexed values
women was 43.7 mm, which falls within this previously
RVED area (cm2/m2) ≤12.6
RA area (cm2/m2) ≤11 published range, confirming that the current values are
Absolute values not dramatically different from what may have been
RVOT proximal (mm) 20–42 expected.
RVOT distal (mm) 14–28
The upper reference limit for the RV mid-point
RVD1 (mm) 22–43
RVD2 (mm) 17–35 diameter is now 42 mm (males) and 35 mm (females).
RVD3 (mm) 51–80 Again, these are slightly larger than the previous
RA area (cm2) ≤19 guidance, but for all the reasons outlined above, there is
Right heart function
FAC (%) ≥35
no fundamental conflict with previously published data.
The RVOT should be measured using 2D imaging from
FAC, fractional area change; RA, right atrial; RVD1, right ventricular basal the PSAX window. Using the NORRE dataset, the upper
diameter in diastole; RVD2, right ventricular mid-point diameter in diastole;
reference limits for the RVOT demonstrate substantial
RVD3, right ventricular length in diastole; RVED, right ventricular end-
diastolic area, obtained from the RV-optimised apical 4-chamber view; differences from previously accepted guidelines: in males
RVOT distal, right ventricular outflow tract at the level of the pulmonary the URL is 44 mm, whereas for females it is 42 mm. This
valve from the parasternal short axis window; RVOT proximal, proximal
is larger than previously described, when the universal
right ventricular outflow tract obtained from the parasternal short
axis view. cut-off for both men and women was 35 mm. It is not
immediately apparent why the current results appear to
heart parameters within its dataset, from which the be larger than earlier work had suggested. For the distal
BSE propose an upper reference limit for indexed RVED RVOT, the current reference limits are very similar to
area of 13.6 cm2/m2 (males) and 12.6 cm2/m2 (females), previously published guidance.
with an upper reference limit for indexed RA area of 11 RV fractional area change is a useful tool to assess RV
cm2/m2 for both men and women. function. NORRE demonstrated that there is a significant
A potential limitation of indexed right heart area difference between men and women with regards values
parameters is that the inter-observer variability is inferior for FAC: for males the lower reference limit is 30% whereas
to conventional linear measurements (8). For this reason, for females it is 35%.
the BSE advocates that the indexed area is combined with
conventional linear measures in all patients. Clinical implications
Reference limits for linear dimensions have also been Two potential clinical impacts of the new reference
updated using the NORRE data. With regards the RV basal intervals for the right heart are in the echocardiographic
diameter (RVD1), the BSE defines the upper reference limit assessment of pulmonary hypertension (PH) and
for males as 47 mm, whereas for females the URL is 43 arrhythmogenic right ventricular cardiomyopathy
mm. These values are larger than the currently published (ARVC).
reference limit of 41 mm for both men and women. The ASE A major criterion for the diagnosis of ARVC is the
defined the current value in 2010, using pooled data from presence of regional RV wall motion abnormalities,
10 studies, including a combined total of 376 individuals combined either with impaired RV function (defined
(4). The most contemporaneous joint American and as an FAC of ≤33%), or an enlarged RV. This latter was
echocardiography
defined as an RVOT proximal diameter of ≥36 mm Remember, even though the upper limit for RV size has
measured from the PSAX window (57). It appears now increased, if the RV is seen to be larger than the left
challenging to rationalize this major criterion with the ventricle, this should prompt further consideration.
new reference intervals for the RV. However, size of the
RVOT in and of itself is not sufficient to qualify as a major
Aortic dimensions
criterion for the diagnosis of ARVC. Regional wall motion
abnormalities of the RV are the pre-requisite finding, and Summary
only when these are seen does size subsequently play a
•• Aortic dimensions should be measured using 2D
role. Similarly, minor criteria for the diagnosis of ARVC
imaging from the PLAX window.
include an RVOT diameter of between 32 and 36 mm
•• Indices should be obtained using the inner-edge
or a fractional change of ≤40% (both in the context of
to inner-edge (IE-IE) methodology in end-diastole,
regional abnormalities of RV contractility). These minor
defined as the onset of the QRS complex.
criteria for RVOT dimensions and RV function both fall
•• All values should be indexed to height and not BSA.
within the previously published reference limits. The
•• For those echo labs that currently employ the leading-
apparent conflict between the current reference intervals
edge to leading-edge (LE-LE) technique, it is reasonable
and diagnosis of ARVC is therefore not new.
to continue doing so for continuity and consistency.
With regards pulmonary hypertension, recent guidance
•• The BSE suggests that echo labs include the method
by the BSE mirrors earlier work from the EACVI (58, 59). The
of assessment within the echo report to ensure
principle of the PH guidance is to quantify the likelihood
transparency for clinicians.
of pulmonary hypertension being present, rather that
reporting absolute values of pulmonary artery (PA) pressure.
Rationale and discussion
The probability of PH is based primarily upon the tricuspid
Reference limits for the recommended measurements for
regurgitation (TR) maximal velocity, although the presence
aortic root dimensions are presented in Table 7. Aortic
of two additional echo characteristics can subsequently
dimensions should be obtained using the IE-IE technique
increase the likelihood of pulmonary hypertension being
in end-diastole, defined as the onset of the QRS complex
present. Most of these additional echo characteristics are
(Fig. 6). Aortic indices should be indexed for height and
unaffected by the new right heart reference limits. The
not BSA as was previously recommended.
exception is a right atrial area of >18 cm2, which would
Historical measurements of aortic root size used the
now be defined as a normal finding within the current
LE-LE methodology owing to the poor resolution available
reference intervals for both males and females.
at the time. This dimension is neither the outer nor the
We believe that this guideline change is exceptionally
inner size of the aorta, but has resulted in reference values
unlikely to affect clinical practice. According to the
and cut-offs for therapy (such as aortic root replacement)
NORRE data, fewer than 5% of males, and an estimated
that are embedded in contemporary guidance (60).
3% of normal females would be expected to have an
Conversely, there is evidence that measurements of
RA area of >18 cm2. In these individuals, it would need
the aortic root using the IE-IE methodology is more
further supportive echo evidence of PH to potentially
readily obtained and more reproducible (61). Previous
alter the overall likelihood of pulmonary hypertension
BSE guidance has advocated the IE-IE technique, and
being present. These additional echo characteristics are
therefore, to maintain consistency, the current guidance
also very unlikely to occur in normal individuals: for
advises ongoing use of this approach. The BSE suggests
example, a pulmonary acceleration time of <105 ms
that echo labs document how aortic root dimensions are
would be expected to occur in fewer than 2.5% of normal
patients. Therefore, the combined probability of both an
RA area >18 cm2 and a pulmonary acceleration time <105 Table 7 Normal indexed aortic root dimensions.
ms occurring by chance in a normal individual is less than Male Female
1 in 1000. Sinus of Valsalva (mm/m) 13.8–21.8 13.1–20.7
Although the reference intervals for linear right heart Sino-tubular junction (mm/m) 11.4–18.6 11.0–17.8
dimensions do vary from historic guidance, this likely Proximal ascending aorta (mm/m) 11.5–19.9 11.4–19.8
reflects that the source of previous data was somewhat
Inner edge to inner edge methodology; indexed to height; obtained in end-
limited, and NORRE has substantially increased our diastole (onset of QRS). Proximal ascending aorta measures obtained 1 cm
understanding of normal right heart chamber dimensions. above the sino-tubular junction.
echocardiography
age-specific nomograms derived from a single paper by

Roman et al. (62). Despite the authors’ recommending
the use of their nomogram for children only, the adult
versions have been included in virtually all chamber
guidelines and textbooks ever since (5, 6, 63, 64). These
adult nomograms have some limitations: small sample
size, poorly defined ‘normal’ subjects, bias to BSA (which
is adversely affected by obesity), and finally a sharp jump
in results when the subject turns 40 owing to a change
in the equation used. These problems have been well
described elsewhere (65).
In the subsequent 25 years, many studies have
attempted to improve on this. Devereux et al. have
Figure 6 derived equations for aortic root dimensions from 1207
Assessment of aortic root dimensions. The measurements should be apparently normal subjects (66). However, the data were
obtained using the inner-edge to inner-edge methodology in end diastole derived from a mixture of studies, including the original
(defined as the onset of the QRS). Measurements should be obtained at
three levels including: sinus of Valsalva (red line); sino-tubular junction Roman group. The methodology was not pre-specified,
(green line); proximal ascending aorta defined as the region 1 cm above with the aortic root occasionally measured from the
the sino-tubular junction (blue line). If there is enlargement above this apical three-chamber view, which is not used routinely in
level the maximal dimension should be measured and stated in report.
Measurements should be reported after indexing for height. practice and is unlikely to be comparable to results from
the parasternal long-axis window.
obtained within echo reports, particularly if a decision has The NORRE dataset obtained data for normal aortic
been made to alter the methodological approach. root values at four different levels, including the Sinus
On average, aortic dimensions are 1.2 mm smaller of Valsalva, the ST-junction, and the proximal ascending
when using IE-IE compared to LE-LE. The BSE believes aorta (also referred to as the tubular ascending aorta) using
that this is unlikely to have a significant impact on both LE-LE and the IE-IE methodology. Additionally,
clinical decision-making: patients who are close to the NORRE obtained data for aortic dimensions both in
cut-off for surgery invariably undergo additional imaging end-diastole (defined as the onset of the QRS complex)
such as CT or MRI. These modalities can confirm the true and mid-systole, which corresponds to maximal aortic
maximal aortic size, but also have the advantage of being dimensions (10). Consequently, there is a vast array of
able to visualise the entire aorta (a necessary step before data from which reference limits can be derived.
surgery) and obtain a true co-axial slice through the aorta. NORRE, along with earlier work by Oxborough et al.,
CT also has the potential to obtain information on the demonstrated that aortic root dimensions are best
coronary arteries, which may avoid the need for invasive correlated to height and not BSA (10, 61). This is a change
angiography. from the currently accepted practice and will have
The aorta should be measured at end-diastole, as potential benefits in overweight individuals. Indexing to
this measurement is more reproducible, at least in part height also results in similar reference limits for younger
owing to the clear timing reference, whereas mid-systole and older individuals alike and therefore greatly simplifies
is less easy to define (61). This will make echo surveillance the reference intervals.
with sequential measurements of a dilating aorta more
reproducible. Aortic dimensions obtained in diastole are
consistently smaller than corresponding measurements Table 8 Normal indexed aortic root dimensions (leading
made in systole (10, 61). If the aorta in question is edge-leading edge methodology).
approaching the point at which intervention is required, Male Female
the BSE suggests that corroborative measurements are Sinus of Valsalva (mm/m) 14.8–23.2 14.1–22.1
made with an additional imaging modality. Sino-tubular junction (mm/m) 12.6–19.8 12.2–19.4
Traditionally, nomograms have been used to present Proximal ascending aorta (mm/m) 12.6–21.4 12.3–21.1
reference intervals in a visually appealing way as it
Leading edge to leading edge methodology; indexed to height; obtained in
varies against a dependent variable, such as BSA. The end-diastole (onset of QRS). Proximal ascending aorta measures obtained
aortic root diameter has been compared against three 1 cm above the sino-tubular junction.
echocardiography
Table 9 Normal tissue Doppler parameters. Summary

Normal
The BSE believe that the current guidance provides robust
Males and females
reference intervals for use in day-to-day practice in UK
Mean mitral annular s′ (cm/s)
20–40 years ≥6.4 echo labs. This report contains guidance only and should
40–60 years ≥5.7 also be used in conjunction with clinical assessment and
>60 years ≥4.9 interpretation. The reference intervals within should not
RV s′ (cm/s)
be used as the sole reason for making clinical decisions for
All ages ≥9
individual patients.
For those echo departments currently utilising the

LE-LE methodology, it is reasonable to continue this
Supplementary materials
practice for consistency. New reference limits for the
This is linked to the online version of the paper at https://doi.org/10.1530/
LE-LE methodology are presented in Table 8. ERP-19-0050.
Tissue Doppler imaging

Declaration of interest
Tissue Doppler imaging (TDI) is a useful technique that David Oxborough and Vishal Sharma are members of the editorial board
is both robust and reproducible. Values for the left heart of Echo Research and Practice. They were not involved in the editorial or
should be obtained as the average of medial and lateral peer review process of this paper, on which they are listed as authors. The
other authors have nothing to disclose.
mitral annular systolic velocities, and obtained during a
breath hold in end-expiration. Values are similar for both
men and women, but vary according to age (Table 9).
Right ventricular TDI values should be obtained from Funding
the lateral RV annulus. RV indices are similar for males This work did not receive any specific grant from any funding agency in the
public, commercial or not-for-profit sector.
and females and do not vary significantly according to
age (Table 9).
Acknowledgements
The authors’ would like to thank Dr Mark Belham for his thoughts and
Strain values
assistance, and the Education Committee of the British Society for
Echocardiography for their support. They also acknowledge the authors of
The BSE has chosen not to include reference limits for strain
NORRE who provided clarification of their published data in order for us to
parameters. Unfortunately, there is still significant inter- finalise the BSE reference limits.
vendor variability, such that a single reference interval
would not suffice for all practitioners. Additionally, it is
not clear whether different versions of strain software give
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A Harkness, L Ring et al.

Reference limits for 7:1 G1–G18

GUIDELINES AND RECOMMENDATIONS

Normal reference intervals for cardiac

5North West Anglia NHS Foundation Trust, Peterborough, UK

6Royal Liverpool and Broadgreen University Hospitals NHS Trust, Liverpool, UK

Correspondence should be addressed to L Ring: liamring@doctors.org.uk

*(A Harkness and L Ring contributed equally to this work)

†(D X Augustine and V Sharma are the Guidelines Chairs)

Introduction Table 1 Echocardiographic parameters covered by the BSE

Echocardiography in athletes should also be interpreted BSE reference intervals

Left ventricular volumes

Reference intervals for LV volumes are presented in

Table 3 Left ventricular volumes.

Mildly Moderately Severely

Volumes obtained using the biplane Simpson’s method.

Left ventricular ejection fraction Table 4 Left ventricular ejection fraction.

females (Table 4). Males and females

age-specific nomograms derived from a single paper by

Table 9 Normal tissue Doppler parameters. Summary

For those echo departments currently utilising the

Tissue Doppler imaging

Received in final form 9 December 2019

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