EchoCompass

ASE 2025: the simplified script

1. Check three things: e′ (septal 6 or less, lateral 7 or less, or average 6.5 or less), E/e′ (average 14 or more), TR 2.8 m/s or more (or PASP 35 or more).
2. All three abnormal: LAP elevated. Grade with E/A: below 2 is Grade 2, 2 or more is Grade 3.
3. All three normal: normal diastolic function.
4. Only e′ reduced: E/A 0.8 or less is Grade 1. Above 0.8, go to step 5.
5. Anything else (one or two abnormal): check LAVI above 34, LARS 18% or less, pulmonary vein S/D 0.67 or less, or IVRT 70 ms or less. Any one positive means LAP is elevated; grade with E/A.
6. None positive: LAP is normal (Grade 1 if e′ is reduced).
7. No additional markers: use supplemental signs (PR end-diastolic velocity, L-wave, Ar minus A, Valsalva).

Grade 1 in a symptomatic patient: the guideline recommends a diastolic exercise echo.

What changed from 2016

• One algorithm for every EF. The A and B split is gone.
• The first step is e′, E/e′ and TR, not mitral inflow.
• e′ cutoffs are lower (6, 7 and 6.5), with optional age-specific values.
• E/e′ and TR thresholds now include equality: 14 or more and 2.8 or more.
• LAVI moved to the second line, joined by LA strain, pulmonary vein S/D and IVRT.
• E/A grades the dysfunction after LAP is decided.
• Supplemental signs reduce indeterminate results.
• Separate approaches for AF, MAC, MR, MS, PH, transplant and LVAD.

2016 script (for older exams)

1. Normal EF and myocardium: count e′, E/e′ above 14, TR above 2.8, LAVI above 34. More than half abnormal is dysfunction; half is indeterminate.
2. Then, or if EF is reduced or the myocardium is abnormal: E/A 0.8 or less with E 50 or less is Grade 1; E/A 2 or more is Grade 3.
3. Otherwise count E/e′, TR and LAVI. Majority decides Grade 1 or 2; a two-criteria split is indeterminate.

Traps: septal and lateral e′ count once, E/A 0.8 or less needs E 50 or less to stop, a 1:1 split is never Grade 1.

Fluids: three questions, kept apart

1. Need: is there hypoperfusion? Without it, a positive responsiveness test is just normal physiology.
2. Respond: use a dynamic test. PLR with VTI (10% or more) works in most patients. PPV needs strict conditions.
3. Tolerate: elevated LAP, diffuse B-lines, VExUS 2 or 3, or RV dysfunction make the patient likely intolerant. So do two or more clinical overload signs.

There’s no validated fluid tolerance score. The tool combines markers the way you would at the bedside and says so.

LV assessment and shock

1. Separate pump from flow: EF tells you contractility, LVOT VTI tells you output. A weak LV can still deliver enough flow.
2. Shock severity comes from pressure, flow and perfusion, never from EF (SCAI SHOCK 2022 domains, applied to every shock type). Pre-shock (B): hypotension, tachycardia or low flow with lactate below 2 and no hypoperfusion. Shock (C): lactate 2 or more, ScvO₂ below 70, clinical hypoperfusion, or a vasopressor needed. Severe (D range): any of lactate 4 or more, VTI below 10 cm, CI below 1.8 or SVI below 25, MAP below 65 despite two vasopressors or a moderate or higher dose, two vasoactive drugs or high-dose norepinephrine, or lactate rising since the last time point. Extremis (E range): lactate 8 or more with MAP below 65 despite very high-dose or two vasopressors. The lactate 4 and very-low-flow cut points are EchoCompass teaching thresholds for grading a single assessment, not SCAI criteria.
3. Infection likelihood: strong with a positive blood culture (likely pathogen), or a clear source plus two of fever or hypothermia, abnormal WBC and procalcitonin above 2. Moderate when findings are discordant. Unlikely when every item entered (at least three) is negative. Septic shock is named only when infection is strong and Sepsis-3 criteria are met (vasopressor for MAP 65 or more and lactate above 2); with moderate evidence and shock, the report says possible septic shock and advises antibiotics within 1 hour.
4. RV by ASE 2025: TAPSE above 17 mm, s′ above 9.5 cm/s and FAC above 35% are normal; TAPSE below 10 mm, s′ below 5 cm/s and FAC 22% or less are severe.
5. Always look for dynamic LVOT obstruction before starting an inotrope.
6. MAP first with norepinephrine, then preload, then an inotrope if hypoperfusion persists with low flow.
7. Choose dobutamine or milrinone by patient factors: AKI, tachyarrhythmia, hypotension, beta-blockade, RV failure.
8. RV failure: avoid fluid when the RV is dilated, keep MAP up with norepinephrine (vasopressin as an adjunct), optimize ventilation, keep sinus rhythm, treat the cause (thrombolysis for high-risk PE, revascularization for RV infarction), and escalate early to the shock team.
9. Set a working diagnosis, but let the echo challenge it: the tool flags findings that don’t fit.

About the action tiers: the cut points that separate “Do now” from “Consider” (LVOT VTI below 15 cm, cardiac index below 2.2 L/min/m², lactate above 4 mmol/L, ScvO₂ below 60%) are pragmatic bedside thresholds chosen for teaching. They are not validated decision rules, and they should always be read alongside the trend and the clinical picture. Capillary refill uses the 3-second threshold from ANDROMEDA-SHOCK.