The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: Data from the SHORTWAVE study

https://doi.org/10.1016/j.diabres.2013.07.004Get rights and content

Abstract

Aims

Type 2 diabetes mellitus (DM) is associated with higher risk of heart failure. Over the last three decades several studies demonstrated the presence of asymptomatic systolic and/or diastolic left ventricular (LV) dysfunction (asymLVD) in patients with normal LV ejection fraction (LVEF). Purpose of our study was to assess the prevalence and factors associated with asymLVD in DM patients by echocardiographic indexes more sensitive than LVEF and transmitral flow detected by pulsed Doppler.

Methods

386 DM patients without overt cardiac disease were enrolled from January to October 2011. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S′) were considered as indexes of systolic function of circumferential and longitudinal myocardial fibers, respectively. Early diastolic velocity of transmitral flow was divided by early diastolic Tissue Doppler velocity of mitral annulus for identifying diastolic LVD.

Results

asymLVD was detected in 262 patients (68%). 106 (27%) had isolated systolic asymLVD, 61 (16%) isolated diastolic asymLVD; in 95 (25%) systolic and diastolic asymLVD coexisted. Patients with asymLVD were older, had lower glomerular filtration rate, higher levels of glycated hemoglobin, C reactive protein, LV mass, relative wall thickness and prevalence of valve calcifications. Older age (HR 1.1 [1.02–1.18], p = 0.01), aortic valve calcifications (HR 6.3 [1.31–30.31], p = 0.02), LV concentric geometry defined as relative wall thickness ≥0.43 (HR 15.44 [2.96–80.44], p = 0.001) were independent predictors of asymLVD at multivariate analysis.

Conclusions

Using suitable echocardiographic indexes, asymLVD is detectable in two/third of DM patients without overt cardiac disease and is predicted by older age, cardiac valve calcifications and LV concentric remodeling.

Introduction

Type 2 diabetes is associated with significantly higher risk of heart failure (HF) and coronary artery disease (CAD), and its prevalence is rapidly assuming epidemic proportions due to the aging population and prevalence of obesity, with a profound impact on health care [1], [2]. Increased prevalence of HF in type 2 diabetes patients persists despite correction for age, arterial hypertension, obesity, hypercholesterolemia, and CAD, thus leading to the proposal of a primary myocardial disease, diabetic cardiomyopathy [3].

Over the last three decades several studies have demonstrated the presence of asymptomatic diastolic left ventricular (LV) dysfunction in patients with normal LV ejection fraction (LVEF) suggesting that myocardial damage in type 2 diabetes patients affects diastolic function before systolic function [4], [5], [6], [7], [8]. However, more recently, several studies [5], [9], [10], [11], [12], [13], [14], [15] have clearly shown that diabetic cardiomyopathy often arises as pure systolic asymptomatic LVD. Such evidences have been made possible by the use of echocardiographic techniques and measures alternative to and more accurate than LVEF, which largely underestimates the prevalence of asymptomatic LVD in type 2 diabetes patients, particularly in those who have concentric LV geometry [5], [10].

Aims of this study were to assess, in patients with type 2 diabetes without history of cardiac disease or inducible myocardial ischemia, the prevalence and the clinical characteristics of systolic and/or diastolic asymptomatic LVD, by means of midwall shortening and Tissue Doppler echocardiography that have never been used in combination in these patients.

Section snippets

Study population

SHORTWAVE (SHORTening of midWall and longitudinAl left Ventricular fibers in diabEtes) experience was a prospective, multicenter study evaluating clinical and echocardiographic characteristics of a large cohort of individuals with type 2 diabetes. Study participants were non-institutionalized subjects >18 years of age with type 2 diabetes diagnosed by World Health Organization criteria (fasting serum glucose ≥126 mg/dl or 2-h post-challenge serum glucose ≥200 mg/dl or use of hypoglycemic

Results

The study populations consisted of 386 patients with type 2 diabetes whose main clinical and echocardiographic characteristics are shown in Table 1, Table 2. More than one third of the patients were obese, suffered from hypertension; metabolic syndrome was diagnosed in one out of two patients.

Discussion

In this study we demonstrated that: (1) asymLVD is present in two third of patients with type 2 diabetes without a history of cardiac disease and inducible myocardial ischemia; (2) prevalence of systolic asymptomatic LVD is similar to or even higher than diastolic asymptomatic LVD, and systolic and diastolic asymptomatic LVD coexist in a significant proportion (one quarter) of patients; (3) older age, cardiac valve calcifications and LV concentric remodeling depict the phenotype of type 2

Conflict of interest

Each author discloses funding sources that supported her/his work and any commercial associations, current and over the past 5 years, that might pose a conflict of interest.

Authors’ contributions

Giovanni Cioffi: conception and design, research data, statistical analysis, discussion and editings.

Giacomo Faden: research data, writer.

Giorgio Faganello, Andrea Di Lenarda, Stefania De Feo, Nicola Berlinghieri, Luigi Tarantini and Pompilio Faggiano were involved in the conception and design of the protocol, researched data and contributed to the discussion.

Giovanni Cioffi and Pompilio Faggiano are the guarantors of this work and take responsibility for the integrity of data and the accuracy

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