There is controversy regarding the nature of systolic function in patients with elevated filling pressure and preserved left ventricular (LV) ejection fraction. In this study, tissue Doppler variables and 2-dimensional echocardiographic systolic strain (SS) and systolic strain rate (SSr) were measured in patients who underwent cardiac catheterization to determine correlations with invasively measured LV end-diastolic pressure (LVEDP), dP/dt, and LV mass. Forty patients were studied. Their mean age was 55.9 ± 9.9 years, and their mean LV ejection fraction was 59.8 ± 5.2%. Tissue Doppler systolic annular velocity (5.4 ± 1.1 vs 6.4 ± 1.0 cm/s, p = 0.04), SS (13.4 ± 3.7% vs 18.8 ± 2.3%, p <0.001), and SSr (0.73 ± 0.17 vs 0.98 ± 0.14 s⁻¹, p <0.001) were significantly lower in patients with LVEDP >20 mm Hg compared with those with LVEDP <20 mm Hg. Tissue Doppler systolic velocity, SSr, and SS were correlated with LV mass (R = 0.58, R = 0.57, and R = 0.52, respectively, all p values <0.001) and with LVEDP (R = 0.49, p = 0.002; R = 0.79, p <0.001; and R = 0.70, p <0.001, respectively). However, dP/dt was not significantly different between patients with LVEDP >20 mm Hg and those with LVEDP <20 mm Hg (1,387 ± 520 vs 1,495 ± 594 mm Hg/s, respectively, p = 0.55) and was not correlated with LV mass (R = 0.18, p = 0.25). The optimum cut-off values for LVEDP >20 mm Hg were SSr <0.85 s⁻¹ (area under the curve 0.88, p <0.001, positive predictive value 89%, negative predictive value 86%) and SS <16% (area under the curve 0.84, p = 0.002, positive predictive value 88%, negative predictive value 79%). In conclusion, as opposed to invasively measured dP/dt, tissue Doppler systolic velocity and 2-dimensional echocardiographic SS and SSr are significantly depressed in patients with preserved LV ejection fraction and LVEDP >20 mm Hg, suggesting that systolic abnormalities are present in at least some of these patients. These differences are likely because invasively measured dP/dt and these echocardiographic variables measure different systolic properties in patients with preserved LV ejection fraction.