Prevalence of systolic and diastolic dysfunction in patients with type 1 diabetes without known heart disease: the Thousand & 1 Study

The role of aetiology in cardiac manifestations of chronic kidney disease: the CPH-CKD ECHO study

PURPOSE

We investigated the associations between cardiac parameters and aetiologies of CKD in an exploratory study.

METHODS

The study population consisted of 883 participants, 174 controls and 709 patients with aetiologies of CKD including diabetic nephropathy/renovascular KD in diabetes mellitus, hypertensive/renovascular nephropathy, tubulointerstitial nephritis, glomerulonephritis/vasculitis, polycystic KD (PKD), and CKD of unknown origin. Echocardiographic measures included left ventricular (LV) ejection fraction, global longitudinal, area, and radial strain, E/e' ratio, and LV mass index. These were compared between each aetiological group and controls in unadjusted and adjusted analysis.

RESULTS

In unadjusted analysis, patients with diabetic nephropathy/renovascular KD in diabetes mellitus, had impaired LV ejection fraction (Median [IQR]: 56% [49.9,60.69] vs. 60.8% [57.7,64.1]), global longitudinal (mean ± SD: 13.1 ± 3.5% vs. 15.5 ± 2.6%), area (24.1 ± 5.8% vs. 28.5 ± 4.2%), and radial strain (36.2 ± 11.2% vs. 44.1 ± 9.7%), and increased LV mass index (89.1 g/m2 [71.8,104.9] vs. 69,0 g/m2 [57.9,80.8]) and E/e' ratio (10.6 [8.5,12.6] vs. 7 [5.8,8.3], p < 0.001 for all) compared with controls. Associations were similar for CKD of unknown origin. Patients with hypertensive/renovascular nephropathy had impaired global longitudinal and area strain, and higher E/e' ratio. Patients with glomerulonephritis/vasculitis had higher LV mass index, while patients with PKD had better global longitudinal strain than controls. All findings remained significant in adjusted analysis, except for the impaired global longitudinal strain in hypertensive/renovascular nephropathy.

CONCLUSION

Glomerulonephritis/vasculitis, hypertensive/renovascular nephropathy, CKD of unknown origin, and diabetic nephropathy/renovascular KD in diabetes mellitus were increasingly associated with adverse cardiac findings, while PKD and tubulointerstitial nephritis were not. Aetiology might play a role regarding the cardiac manifestations of CKD.

Ratio of transmitral early filling velocity to diastolic strain rate and prognosis in type-1 diabetes

BACKGROUND

Impaired diastolic function is a hallmark of diabetic cardiomyopathy and a common feature in type 1 diabetes mellitus (T1DM). The ratio of transmitral early filling velocity to early diastolic strain rate (E/e'sr) has in recent studies proved to have strong prognostic value. This study aimed to investigate the prognostic value of E/e'sr compared to E/e' in T1DM without known heart disease.

METHODS

In this prospective cohort of T1DM patients, echocardiography was performed including two-dimensional speckle tracking. Follow-up was performed using nationwide registries. Outcomes were all-cause mortality and major cardiovascular events (MACE).

RESULTS

In total 1079 patients (age: 49.6 ± 14.5 years, 52.5% male, duration of diabetes 25.8 ± 14.6 years) were included in the study. During follow-up (median 6.3 years, IQR:5.7-6.9) 13.2% experienced MACE and 5.8% died. Following multivariable adjustment, both E/e'sr and E/e' was significantly associated with both MACE (E/e'sr: HR 1.16 CI95%:[1.05-1.29], p = 0.005, per 10 cm increase) vs. (E/e': HR 1.09 CI95%:[1.03-1.15], p = 0.001, per 1 unit increase) and all-cause mortality (E/e'sr: HR 1.20 [1.03-1.40], p = 0.016) vs. (E/e': HR: 1.11 [1.02-1.20], p = 0.016). Sex modified the association between E/e'sr and MACE (p for interaction = 0.008) such that E/e'sr after multivariable adjustment only remained significantly associated with MACE in females (HR: 1.41 [1.19-1.67], p < 0.001) but not in males (HR: 1.06 [0.93-1.20], p = 0.42). In females, E/e'sr provided incremental information beyond the Steno T1 Risk Engine (Harrell's C-statistic: 0.78 (0.72-0.83) vs. 0.81 (0.75-0.86), p = 0.007).

CONCLUSION

In patients with T1DM, both E/e'sr and E/e' provides independent prognostic information regarding prognosis. E/e'sr seems to have stronger prognostic value in females with T1DM.

The double burden: type 1 diabetes and heart failure-a comprehensive review

Heart failure (HF) is increasing at an alarming rate, primary due to the rising in aging, obesity and diabetes. Notably, individuals with type 1 diabetes (T1D) face a significantly elevated risk of HF, leading to more hospitalizations and increased case fatality rates. Several risk factors contribute to HF in T1D, including poor glycemic control, female gender, smoking, hypertension, elevated BMI, and albuminuria. However, early and intensive glycemic control can mitigate the long-term risk of HF in individuals with T1D. The pathophysiology of diabetes-associated HF is complex and multifactorial, and the underlying mechanisms in T1D remain incompletely elucidated. In terms of treatment, much of the evidence comes from type 2 diabetes (T2D) populations, so applying it to T1D requires caution. Sodium-glucose cotransporter 2 inhibitors have shown benefits in HF outcomes, even in non-diabetic populations. However, most of the information about HF and the evidence from cardiovascular safety trials related to glucose lowering medications refer to T2D. Glycemic control is key, but the link between hypoglycemia and HF hospitalization risk requires further study. Glycemic variability, common in T1D, is an independent HF risk factor. Technological advances offer the potential to improve glycemic control, including glycemic variability, and may play a role in preventing HF. In summary, HF in T1D is a complex challenge with unique dimensions. This review focuses on HF in individuals with T1D, exploring its epidemiology, risk factors, pathophysiology, diagnosis and treatment, which is crucial for developing tailored prevention and management strategies for this population.

Novel model predicts diastolic cardiac dysfunction in type 2 diabetes

OBJECTIVE

Diabetes mellitus complicated with heart failure has high mortality and morbidity, but no reliable diagnoses and treatments are available. This study aimed to develop and verify a new model nomogram based on clinical parameters to predict diastolic cardiac dysfunction in patients with Type 2 diabetes mellitus (T2DM).

METHODS

3030 patients with T2DM underwent Doppler echocardiography at the First Affiliated Hospital of Shenzhen University between January 2014 and December 2021. The patients were divided into the training dataset (n = 1701) and the verification dataset (n = 1329). In this study, a predictive diastolic cardiac dysfunction nomogram is developed using multivariable logical regression analysis, which contains the candidates selected in a minor absolute shrinkage and selection operator regression model. Discrimination in the prediction model was assessed using the area under the receiver operating characteristic curve (AUC-ROC). The calibration curve was applied to evaluate the calibration of the alignment nomogram, and the clinical decision curve was used to determine the clinical practicability of the alignment map. The verification dataset was used to evaluate the prediction model's performance.

RESULTS

A multivariable model that included age, body mass index (BMI), triglyceride (TG), creatine phosphokinase isoenzyme (CK-MB), serum sodium (Na), and urinary albumin/creatinine ratio (UACR) was presented as the nomogram. We obtained the model for estimating diastolic cardiac dysfunction in patients with T2DM. The AUC-ROC of the training dataset in our model was 0.8307, with 95% CI of 0.8109-0.8505. Similar to the results obtained with the training dataset, the AUC-ROC of the verification dataset in our model was 0.8083, with 95% CI of 0.7843-0.8324, thus demonstrating robust. The function of the predictive model was as follows: Diastolic Dysfunction = -4.41303 + 0.14100*Age(year)+0.10491*BMI (kg/m2) +0.12902*TG (mmol/L) +0.03970*CK-MB (ng/mL) -0.03988*Na(mmol/L) +0.65395 * (UACR > 30 mg/g) + 1.10837 * (UACR > 300 mg/g). The calibration plot diagram of predicted probabilities against observed DCM rates indicated excellent concordance. Decision curve analysis demonstrated that the novel nomogram was clinically useful.

CONCLUSION

Diastolic cardiac dysfunction in patients with T2DM can be predicted by clinical parameters. Our prediction model may represent an effective tool for large-scale epidemiological study of diastolic cardiac dysfunction in T2DM patients and provide a reliable method for early screening of T2DM patients with cardiac complications.KEY MESSAGESThis study used clinical parameters to predict diastolic cardiac dysfunction in patients with T2DM. This study established a nomogram for predicting diastolic cardiac dysfunction by multivariate logical regression analysis. Our predictive model can be used as an effective tool for large-scale epidemiological study of diastolic cardiac dysfunction in patients with T2DM and provides a reliable method for early screening of cardiac complications in patients with T2DM.

Female is Associated with Left Ventricular Diastolic Dysfunction in Patients with Type 2 Diabetes

Aim

Diabetic cardiomyopathy is a subset of heart disease that is directly associated with diabetes, and left ventricular diastolic dysfunction is the earliest sign. We aimed to investigate the association between sex differences and left ventricular diastolic function in patients with type 2 diabetes.

Methods

This was a cross-sectional study included patients with type 2 diabetes who visit the National Metabolic Management Center (MMC) at the First People's Hospital of Yunnan from 2018 to 2021. Patients with hypertension, history of heart disease or ejection fraction <50% were excluded from the study. Logistic regression was used to analyze their associations.

Results

A total of 1778 patients were included in the study. The study included 1205 (70%) males and 573 (30%) females. Compared with males, females had higher total cholesterol and LDL cholesterol levels but lower diastolic pressure, body mass index (BMI), visceral fat area, HbA1c, blood urea nitrogen (BUN), serum creatinine and triglyceride. Females had a relatively higher ejection fraction than males (68.17 ± 6.055 vs 67.5 ± 6.096, P < 0.05). More female patients than male patients in the age group of 45-60 years old had left ventricular diastolic dysfunction (female vs male, 54.5% vs 46.9%, P < 0.05). We also found that females were independently associated with left ventricular diastolic dysfunction, after adjusting for important clinical factors.

Conclusion

Left ventricular diastolic function might be worse in female patients with type 2 diabetes. Further study is needed to verify the underlying mechanism.

Hyperlipidemia and Cardiovascular Disease in People with Type 1 Diabetes: Review of Current Guidelines and Evidence

PURPOSE OF REVIEW

In this review, we discuss the prevalence of cardiovascular disease in people with type 1 diabetes. We outline key risk factors associated with increased cardiovascular event rates and discuss the prevalence and mechanisms underlying hyperlipidemia in people with type 1 diabetes. Finally, we summarize the evidence to support early and more aggressive lipid-lowering therapy in people with type 1 diabetes and review current guideline recommendations.

RECENT FINDINGS

Comprehensive treatment of hyperglycemia, hypertension, and hyperlipidemia reduces adverse cardiovascular outcomes in people with type 2 diabetes. In contrast, evidence to support a comparable benefit of intensive cardiovascular risk factor management in people with type 1 diabetes is lacking from prospective, randomized trials and has only been shown in registries. Therefore, current treatment guidelines extrapolate prospective clinical trial evidence obtained in people with type 2 diabetes to provide similar treatment recommendations for people with type 1 and type 2 diabetes. Evidence supports the more aggressive treatment of cardiovascular risk factors in people with type 1 diabetes, who would likely benefit from early risk stratification and comprehensive risk factor management, including aggressive lipid-lowering therapy.

Ferroptosis: roles and molecular mechanisms in diabetic cardiomyopathy

Diabetic cardiomyopathy (DCM) is a serious complication of type 1 and type 2 diabetes, which leads to the aggravation of myocardial fibrosis, disorders involving systolic and diastolic functions, and increased mortality of patients with diabetes through mechanisms such as glycolipid toxicity, inflammatory response, and oxidative stress. Ferroptosis is a form of iron-dependent regulatory cell death that is attributed to the accumulation of lipid peroxides and an imbalance in redox regulation. Increased production of lipid reactive oxygen species (ROS) during ferroptosis promotes oxidative stress and damages myocardial cells, leading to myocardial systolic and diastolic dysfunction. Overproduction of ROS is an important bridge between ferroptosis and DCM, and ferroptosis inhibitors may provide new targets for the treatment of patients with DCM.

Cathelicidin as a marker for subclinical cardiac changes and microvascular complications in children and adolescents with type 1 diabetes

OBJECTIVES

To detect cathelicidin levels in pediatric patients with type 1 diabetes (T1D) as a potential marker for diabetic vascular complications and to assess its relation to diastolic dysfunction as an index for subclinical macrovasculopathy.

METHODS

Totally, 84 patients with T1D were categorized into three groups; newly diagnosed diabetes group (28 patients with a mean age of 12.38 ± 1.99) years, T1D without microvascular complications group (28 patients with a mean age of 13.04 ± 2.27), and T1D with microvascular complications group (28 patients with a mean age of 13.96 ± 2.30). Patients were evaluated using serum cathelicidin levels and echocardiography.

RESULTS

Total cholesterol, microalbuminuria, and cathelicidin levels were significantly higher in patients with microvascular complications when compared to the other two groups (p<0.001). Additionally, carotid intima-media thickness (CIMT) echocardiography values and diastolic functions were significantly higher in patients with complications (p<0.001). Cathelicidin was positively correlated to the duration of diabetes (r=0.542, p<0.001), total cholesterol (r=0.346, p=0.001), recurrence of hypoglycemia (r=0.351, p=0.001), recurrence of diabetes ketoacidosis (r=0.365, p=0.001), CIMT (r=0.544, p<0.001), and E/A values (r=0.405, p<0.001).

CONCLUSIONS

Serum cathelicidin levels can be used as an early marker for the occurrence and progression of vascular complications in patients with T1D.

The novel inflammatory biomarker GlycA and triglyceride-rich lipoproteins are associated with the presence of subclinical myocardial dysfunction in subjects with type 1 diabetes mellitus

BACKGROUND

Subjects with Type 1 diabetes mellitus (T1DM) have an increased incidence of heart failure (HF). Several pathophysiological mechanisms have been involved in its development. The aim of this study was to analyze the potential contribution of the advanced lipoprotein profile and plasma glycosylation (GlycA) to the presence of subclinical myocardial dysfunction in subjects with T1DM.

METHODS

We included subjects from a Danish cohort of T1DM subjects (Thousand & 1 study) with either diastolic and/or systolic subclinical myocardial dysfunction, and a control group without myocardial dysfunction, matched by age, sex and HbA1c. All underwent a transthoracic echocardiogram and an advanced lipoprotein profile obtained by using the NMR-based Liposcale® test. GlycA NMR signal was also analyzed. Systolic dysfunction was defined as left ventricular ejection fraction ≤ 45% and diastolic dysfunction was considered as E/e'≥12 or E/e' 8-12 + volume of the left atrium > 34 ml/m2. To identify a metabolic profile associated with the presence of subclinical myocardial dysfunction, a multivariate supervised model of classification based on least squares regression (PLS-DA regression) was performed.

RESULTS

One-hundred forty-six subjects had diastolic dysfunction and 18 systolic dysfunction. Compared to the control group, patients with myocardial dysfunction had longer duration of diabetes (p = 0.005), and higher BMI (p = 0.013), serum NTproBNP concentration (p = 0.001), systolic blood pressure (p < 0.001), albuminuria (p < 0.001), and incidence of advanced retinopathy (p < 0.001). The supervised classification model identified a specific pattern associated with myocardial dysfunction, with a capacity to discriminate patients with myocardial dysfunction from controls. PLS-DA showed that triglyceride-rich lipoproteins (TGRLs), such as VLDL (total VLDL particles, large VLDL subclass and VLDL-TG content) and IDL (IDL cholesterol content), as well as the plasma concentration of GlycA, were associated with the presence of subclinical myocardial dysfunction.

CONCLUSION

Proatherogenic TGRLs and the proinflammatory biomarker Glyc A are strongly associated to myocardial dysfunction in T1DM. These findings suggest a pivotal role of TGRLs and systemic inflammation in the development of subclinical myocardial dysfunction in T1DM.

Associations between Albuminuria, Estimated GFR and Cardiac Phenotype in a Cohort with Chronic Kidney Disease - The CPH-CKD ECHO Study

OBJECTIVE

Echocardiographic findings in chronic kidney disease (CKD) vary. We sought to estimate the prevalence of abnormal cardiac structure and function in patients with CKD and their association to estimated glomerular filtration rate (eGFR) and urine albumin/creatinine ratio (UACR).

METHODS

We prospectively enrolled 825 outpatients with non-dialysis-dependent CKD, mean age 58± 13 yrs, and 175 matched healthy controls, mean age 60±12 yrs. Echocardiography included assessment of left ventricular (LV) hypertrophy, LV ejection fraction (LVEF), global longitudinal strain (GLS) and diastolic dysfunction according to ASE/EACVI guidelines.

RESULTS

LV hypertrophy was found in 9% of patients vs. 1.7% of controls (p=0.005) was independently associated with UACR (p=0.002). Median LVEF was 59.4% (IQR 55.2, 62.8) in patients vs. 60.8% (57.7, 64.1) in controls (p=0.002). GLS was decreased in patients with eGFR <60ml/min/1.73m² (-17.6%±3.1%) vs. patients with higher eGFR (19.0%±2.2%, p<0.001), who were similar to controls. . Diastolic dysfunction was detected in 55% of patients and in 34% of controls.

LIMITATIONS

Non-random sampling, cross-sectional analysis.

CONCLUSIONS

We report lower prevalence of hypertrophy than previous studies, but similar measurements of systolic and diastolic function. Cardiac remodeling in CKD may be influenced by treatment modalities, demographics, comorbidities and renal pathology.

Association between plasma apolipoprotein M and cardiac autonomic neuropathy in type 1 diabetes

AIM

Diabetes may lead to severe complications e.g. cardiac autonomic neuropathy (CAN) characterized by an increased risk of cardiovascular mortality. CAN is diagnosed by a decreased heart rate viability (HRV). Sphingosine-1-Phosphate (S1P) carried by the HDL-associated apolipoprotein M (apoM) is linked to a reduction in the heart rate, and treatment with an S1P-agonist increases HRV. The present study aimed to investigate if plasma apoM was associated with an increased risk of CAN.

METHODS

The study includes 278 individuals with Type 1 Diabetes recruited from Steno Diabetes Center in Copenhagen from 2010 to 2012.

RESULTS

A change of 0.1 µM plasma apoM was associated with the diagnosis of CAN (Odds ratio: 1.11 (1.02; 1.21), p = 0.013). ApoM plasma levels were also positively associated with CAN when adjusted for age and gender (Odds ratio: 1.11 (1.02; 1.21), p = 0.013) as well as lipids, beta-blockers, blood pressure, and alcohol (Odds ratio: 1.14 (1.04; 1.26), p = 0.005) and Hbga1c and time with diabetes (Odds ratio: 1.13 (1.02; 1.25), p = 0.01). Plasma apoM was also associated with a significantly lower SDNN as well as high frequency power in all adjusted models.

CONCLUSION

Increased plasma apoM was associated with an increased risk of CAN as well as a significant reduction in HRV indices. This could represent changes in parasympathetic activity, but, further studies are needed to also explore additional molecular alterations behind such observations.

Fragmented QRS on electrocardiography as a predictor for diastolic cardiac dysfunction in type 2 diabetes

Aims/Introduction

Diastolic cardiac dysfunction in type 2 diabetes (DD2D) is a critical risk of heart failure with preserved ejection fraction. However, there is no established biomarker to detect DD2D. We aimed to investigate the predictive impact of fragmented QRS (fQRS) on electrocardiography on the existence of DD2D.

Materials and Methods

We included in‐hospital patients with type 2 diabetes without heart failure symptoms who were admitted to our institution for glycemic management between November 2017 and April 2021. An fQRS was defined as an additional R′ wave or notching/splitting of the S wave in two contiguous electrocardiography leads. DD2D was diagnosed according to the latest guidelines of the American Society of Echocardiography.

Results

Of 320 participants, 122 patients (38.1%) had fQRS. DD2D was diagnosed in 82 (25.6%). An fQRS was significantly associated with the existence of DD2D (odds ratio 4.37, 95% confidence interval 2.33–8.20; p < 0.0001) adjusted for seven potential confounders. The correlation between DD2D and diabetic microvascular disease was significant only among those with fQRS. Classification and regression tree analysis showed that fQRS was the most relevant optimum split for DD2D.

Conclusions

An fQRS might be a simple and promising predictor of the existence of DD2D. The findings should be validated in a larger‐scale cohort.

Prevalence and Predictors of Left Ventricular Diastolic Dysfunction in Malaysian Patients With Type 2 Diabetes Mellitus Without Prior Known Cardiovascular Disease

Objective: Existing data showed that left ventricular diastolic dysfunction is common in individuals with type 2 diabetes mellitus (T2DM). However, most of the studies included diabetic patients who have prior cardiovascular disease, which might be the compounding factor for ventricular dysfunction. This study aimed to determine the prevalence and predictors of left ventricular diastolic dysfunction in an Asian population with T2DM without prior cardiovascular disease using the latest recommended echocardiographic assessment for left ventricular diastolic dysfunction.

Design and Participants: This is a cross-sectional study in which eligible patients with T2DM without history of coronary artery disease, heart failure, or valvular heart disease were recruited. Demographic data, diabetic control, comorbidities, microvascular/macrovascular complications, and medications prescribed were recorded. Venous blood was sent to test for B-type natriuretic peptide, and transthoracic echocardiography was performed to assess left ventricular dysfunction.

Setting: This study was performed in a tertiary healthcare center located in Kuala Lumpur, Malaysia.

Results: Of the 301 patients, 83.1% have had T2DM for >10 years, with 45.8% being poorly controlled. Comorbidities include hypertension (77.1%), hyperlipidemia (91.0%), and pre-obesity/obesity (72.9%). Majority had absence of microvascular (albuminuria, retinopathy, and neuropathy) and macrovascular (peripheral vascular disease and stroke) complications. None had raised B-type natriuretic peptide levels, and 93.7% had no symptoms of heart failure. On echocardiographic assessment, 70.1% had left ventricular diastolic dysfunction, and 90.5% had Grade 1/mild severity. Age, ethnicity, insulin therapy, presence of hypertension, and hyperlipidemia were significantly associated with left ventricular diastolic dysfunction. Older T2DM patients of Chinese ethnicity and on insulin are about two times more likely to develop left ventricular diastolic dysfunction.

Conclusion: There was a high prevalence of asymptomatic left ventricular diastolic dysfunction among patients with T2DM without prior known cardiovascular disease. Older age, insulin therapy, and Chinese ethnicity were risk factors for left ventricular diastolic dysfunction in T2DM.

The role of hyperglycaemia in the development of diabetic cardiomyopathy

Diabetes mellitus is a metabolic disorder with a chronic hyperglycaemic state. Cardiovascular diseases are the primary cause of mortality in patients with diabetes. Increasing evidence supports the existence of diabetic cardiomyopathy, a cardiac dysfunction with impaired cardiac contraction and relaxation, independent of coronary and/or valvular complications. Diabetic cardiomyopathy can lead to heart failure. Several preclinical and clinical studies have aimed to decipher the underlying mechanisms of diabetic cardiomyopathy. Among all the co-factors, hyperglycaemia seems to play an important role in this pathology. Hyperglycaemia has been shown to alter cardiac metabolism and function through several deleterious mechanisms, such as oxidative stress, inflammation, accumulation of advanced glycated end-products and upregulation of the hexosamine biosynthesis pathway. These mechanisms are responsible for the activation of hypertrophic pathways, epigenetic modifications, mitochondrial dysfunction, cell apoptosis, fibrosis and calcium mishandling, leading to cardiac stiffness, as well as contractile and relaxation dysfunction. This review aims to describe the hyperglycaemic-induced alterations that participate in diabetic cardiomyopathy, and their correlation with the severity of the disease and patient mortality, and to provide an overview of cardiac outcomes of glucose-lowering therapy.

Pharmacological regulation of cytochrome P450 metabolites of arachidonic acid attenuates cardiac injury in diabetic rats

Diabetic cardiomyopathy (DCM) is a well-established complication of type 1 and type 2 diabetes associated with a high rate of morbidity and mortality. DCM is diagnosed at advanced and irreversible stages. Therefore, it is of utmost need to identify novel mechanistic pathways involved at early stages to prevent or reverse the development of DCM. In vivo experiments were performed on type 1 diabetic rats (T1DM). Functional and structural studies of the heart were executed and correlated with mechanistic assessments exploring the role of cytochromes P450 metabolites, the 20-hydroxyeicosatetraenoic acids (20-HETEs) and epoxyeicosatrienoic acids (EETs), and their crosstalk with other homeostatic signaling molecules. Our data displays that hyperglycemia results in CYP4A upregulation and CYP2C11 downregulation in the left ventricles (LV) of T1DM rats, paralleled by a differential alteration in their metabolites 20-HETEs (increased) and EETs (decreased). These changes are concomitant with reductions in cardiac outputs, LV hypertrophy, fibrosis, and increased activation of cardiac fetal and hypertrophic genes. Besides, pro-fibrotic cytokine TGF-ß overexpression and NADPH (Nox4) dependent-ROS overproduction are also correlated with the observed cardiac functional and structural modifications. Of interest, these observations are attenuated when T1DM rats are treated with 12-(3-adamantan-1-yl-ureido) dodecanoic acid (AUDA), which blocks EETs metabolism, or N-hydroxy-N'-(4-butyl-2-methylphenol)Formamidine (HET0016), which inhibits 20-HETEs formation. Taken together, our findings confer pioneering evidence about a potential interplay between CYP450-derived metabolites and Nox4/TGF-β axis leading to DCM. Pharmacologic interventions targeting the inhibition of 20-HETEs synthesis or the activation of EETs synthesis may offer novel therapeutic approaches to treat DCM.

Prognostic and comparative performance of cardiovascular risk markers in patients with type 2 diabetes

BACKGROUND

Diagnostic tests including echocardiography, albuminuria, electrocardiogram (ECG), high-sensitivity troponin I (hs-TnI), and N-terminal prohormone brain natriuretic peptide (NT-proBNP) have been suggested as cardiovascular (CV) risk predictors in type 2 diabetes. We studied the separate and combined prognostic yield of these risk markers.

METHODS

In all, 1030 patients with type 2 diabetes were recruited from specialized clinics in this prospective cohort study. Full echocardiographic evaluation was feasible in 886 patients in sinus rhythm with adequate image quality. ECG was performed in 998 patients. Albuminuria was measured in 1009 and NT-proBNP/hs-TnI in 933 patients. The end point was a composite of CV events.

RESULTS

The median follow-up was 4.7 years (interquartile range: 4.0-5.3), and 174 patients experienced a CV disease event. All considered markers, except hs-TnI, were significantly (P < .001) associated with the outcome: abnormal echocardiogram (hazard ratio 2.40 [1.70-3.39]), albuminuria 2.01 (1.47-2.76), abnormal ECG (2.27 [1.66-3.08]), high NT-proBNP (>150 pg/mL) 3.05 (2.11-4.40), and hs-TnI 1.12 (0.79-1.59). After adjusting for clinical variables, all remained significantly associated with the end point. However, after adjusting for each other, only NT-proBNP >150 pg/mL remained significantly associated with the end point (2.07 [1.28-3.34], P < .001). Measured by C-statistics, model performance was highest with log₂ (NT-proBNP) (0.70 [0.65-0.75]) and similar to clinical variables alone (0.71 [0.67-0.76]). Combining all risk markers only resulted in a very limited increase in C-statistics (0.69 [0.64-0.74]).

CONCLUSIONS

This study identified NT-proBNP over echocardiography, ECG, and albuminuria in risk prediction in patients with type 2 diabetes. The diagnostic yield in considering more than one risk marker was limited in this population.

The impact of central obesity on the risk of hospitalization or death due to heart failure in type 1 diabetes: a 16-year cohort study

BACKGROUND

Obesity and type 2 diabetes are well-known risk factors for heart failure (HF). Although obesity has increased in type 1 diabetes, studies regarding HF in this population are scarce. Therefore, we investigated the impact of body fat distribution on the risk of HF hospitalization or death in adults with type 1 diabetes at different stages of diabetic nephropathy (DN).

METHODS

From 5401 adults with type 1 diabetes in the Finnish Diabetic Nephropathy Study, 4668 were included in this analysis. The outcome was HF hospitalization or death identified from the Finnish Care Register for Health Care or the Causes of Death Register until the end of 2017. DN was based on urinary albumin excretion rate. A body mass index (BMI)  ≥  30 kg/m² defined general obesity, whilst WHtR  ≥  0.5 central obesity. Multivariable Cox regression was used to explore the associations between central obesity, general obesity and the outcome. Then, subgroup analyses were performed by DN stages. Z statistic was used for ranking the association.

RESULTS

During a median follow-up of 16.4 (IQR 12.4-18.5) years, 323 incident cases occurred. From 308 hospitalizations due to HF, 35 resulted in death. Further 15 deaths occurred without previous hospitalization. The WHtR showed a stronger association with the outcome [HR  1.51, 95% CI (1.26-1.81), z  =  4.40] than BMI [HR 1.05, 95% CI (1.01-1.08), z = 2.71]. HbA_1c [HR 1.35, 95% CI (1.24-1.46), z = 7.19] was the most relevant modifiable risk factor for the outcome whereas WHtR was the third. Individuals with microalbuminuria but no central obesity had a similar risk of the outcome as those with normoalbuminuria. General obesity was associated with the outcome only at the macroalbuminuria stage.

CONCLUSIONS

Central obesity associates with an increased risk of heart failure hospitalization or death in adults with type 1 diabetes, and WHtR may be a clinically useful screening tool.

The Diabetic Cardiomyopathy: The Contributing Pathophysiological Mechanisms

Individuals with diabetes mellitus (DM) disclose a higher incidence and a poorer prognosis of heart failure (HF) than non-diabetic people, even in the absence of other HF risk factors. The adverse impact of diabetes on HF likely reflects an underlying “diabetic cardiomyopathy” (DM–CMP), which may by exacerbated by left ventricular hypertrophy and coronary artery disease (CAD). The pathogenesis of DM-CMP has been a hot topic of research since its first description and is still under active investigation, as a complex interplay among multiple mechanisms may play a role at systemic, myocardial, and cellular/molecular levels. Among these, metabolic abnormalities such as lipotoxicity and glucotoxicity, mitochondrial damage and dysfunction, oxidative stress, abnormal calcium signaling, inflammation, epigenetic factors, and others. These disturbances predispose the diabetic heart to extracellular remodeling and hypertrophy, thus leading to left ventricular diastolic and systolic dysfunction. This Review aims to outline the major pathophysiological changes and the underlying mechanisms leading to myocardial remodeling and cardiac functional derangement in DM-CMP.

Relationship between peripheral neuropathy, diastolic function and adverse cardiovascular outcome in individuals with type 1 diabetes mellitus without known cardiovascular disease: Results from the Thousand & 1 Study

AIMS

To investigate the association between measures of peripheral neuropathy (PN) and impaired left ventricular diastolic function, and the prognosis in patients with type 1 diabetes (T1DM) and no known cardiovascular disease (CVD), and to test the incremental prognostic value of including measures of PN and diastolic function to the established Steno T1 Risk Engine.

METHODS

Echocardiography and quantitative biothesiometry was performed to evaluate diastolic function and PN. The participants were categorized according to severity of diastolic function and PN. The study endpoint was combined cardiovascular (CV) events and all-cause death. Associations were analysed using multivariable regression models. The prognostic capability was assessed with Harrell's C-statistics and tested against the Steno T1 Risk Engine.

RESULTS

A total of 946 individuals (51.5% men) were included. The mean (SD) follow-up was 6 (1.3) years. The total number of CV events and all-cause death were 100. In the multi-adjusted analysis, both PN and impaired diastolic function were associated with increased risk of CV events and all-cause death: severe PN versus no PN: hazard ratio (HR) 2.23 (95% confidence interval [CI] 1.06-4.68; P = 0.035); severe diastolic impairment versus normal function: HR 2.27 (95% CI 1.16-4.44; P = 0.016). Measures of diastolic function improved prognostic capability when added to the Steno T1 Risk Engine: C-statistic 0.797 (95% CI 0.793-0.817) versus 0.785 (95% CI 0.744-0.825; P = 0.006).

CONCLUSION

Peripheral neuropathy and impaired diastolic function are associated with an increased risk of CV events and all-cause death in patients with T1DM. Measures of diastolic function improved prediction of prognosis by the Steno T1 Risk Engine.

Prognostic value of ratio of transmitral early filling velocity to early diastolic strain rate in patients with Type 2 diabetes

AIMS

The ratio of early mitral inflow velocity to global diastolic strain rate (E/e'sr) has recently emerged as a novel measure of left ventricular filling pressure. E/e'sr has in previous studies demonstrated to have good prognostic value in various patient populations. The aim of this study is to investigate the prognostic value of E/e'sr in a large cohort of patients with Type 2 diabetes in relation to cardiovascular morbidity and mortality.

METHODS AND RESULTS

In this prospective study, 848 Type 2 diabetic patients (mean age 63.6 ± 10.3 years, 64.7% male) underwent comprehensive echocardiographic examination including 2D speckle tracking in which E/e'sr along with novel and conventional echocardiographic variables were obtained. During follow-up (median: 4.8 years, interquartile range: 4.0-5.3), 122 (14.1%) met the composite outcome of cardiovascular disease, hospitalization, and mortality. Both E/e'sr and E/e' were significantly associated with the outcome [E/e'sr: hazard ratio (HR) 1.07, 95% confidence interval (CI): 1.05-1.10; P < 0.001, per 0.10 m increase] and (E/e': HR 1.07, 95% CI: 1.05-1.10; P = 0.001, per 1 unit increase). E/e'sr remained an independent predictor after multivariable adjustment for demographical, clinical, and echocardiographic parameters (HR 1.06, 95% CI: 1.01-1.12; P = 0.032, per 10 cm increase). The same was true for E/e' (HR 1.09, 95% CI: 1.04-1.14; P < 0.001, per 1 unit increase). Additionally, E/e'sr provided incremental prognostic information beyond the UK 'Prospective Diabetes Study risk engine' 0.72 (0.68-0.77) vs. 0.74 (0.70-79), P = 0.040.

CONCLUSION

In patients with Type 2 diabetes, E/e'sr provides independent and incremental prognostic information regarding cardiovascular morbidity and mortality.

Myocardial glucotoxicity: Mechanisms and potential therapeutic targets

Besides coronary artery disease, which remains the main cause of heart failure in patients with diabetes, factors independent of coronary artery disease are involved in the development of heart failure in the onset of what is called diabetic cardiomyopathy. Among them, hyperglycaemia - a hallmark of type 2 diabetes - has both acute and chronic deleterious effects on myocardial function, and clearly participates in the establishment of diabetic cardiomyopathy. In the present review, we summarize the cellular and tissular events that occur in a heart exposed to hyperglycaemia, and depict the complex molecular mechanisms proposed to be involved in glucotoxicity. Finally, from a more translational perspective, different therapeutic strategies targeting hyperglycaemia-mediated molecular mechanisms will be detailed.

Prognostic Value of Early Systolic Lengthening by Strain Imaging in Type 2 Diabetes

BACKGROUND

Patients with type 2 diabetes (T2D) have increased risk for subclinical myocardial disease. Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, is a sensitive marker of myocardial dysfunction. The aims of this study were to investigate the prognostic value of ESL in patients with T2D and to determine if global longitudinal strain (GLS) modifies this relationship.

METHODS

In this prospective study, speckle-tracking echocardiography was conducted in 703 patients with T2D (62% men; mean age, 63 ± 10 years; median diabetes duration, 11 years; interquartile range, 6-17 years). Patients had no histories of significant heart disease. ESL index was assessed as [-100 × (peak positive systolic strain/maximal strain)] and ESL duration as time from QRS complex on the electrocardiogram to time of peak positive systolic strain. P values ≤ .004 were considered to indicate statistical significance.

RESULTS

During a median follow-up time of 4.8 years (interquartile range, 4.1-5.3 years), 86 patients (12%) experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction, and cardiovascular death. In multivariate models, only the ESL index (hazard ratio [HR], 1.06 per 1% increase; 95% CI, 1.01-1.010; P = .004) but not ESL duration (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.03; P = .036) were associated with MACE. GLS modified this relationship (P for interaction < .05) such that in patients with low GLS (>-18%), ESL index (HR, 1.06 per 1% increase; 95% CI, 1.02-1.10; P = .003) was associated with MACE, but ESL duration was not (HR, 1.02 per 1-ms increase; 95% CI, 1.00-1.04; P = .005). No associations were found for high GLS (<-18%).

CONCLUSIONS

In patients with T2D and no histories of heart disease, ESL provides prognostic information on MACE and may potentially aid in cardiovascular risk stratification.

MR-proANP and incident cardiovascular disease in patients with type 2 diabetes with and without heart failure with preserved ejection fraction

Background

Mid-regional pro-atrial natriuretic peptide (MR-proANP) is a useful biomarker in outpatients with type 2 diabetes (T2D) to diagnose heart failure (HF). Elevated B-type natriuretic peptides are included in the definition of HF with preserved ejection fraction (HFpEF) but little is known about the prognostic value of including A-type natriuretic peptides (MR-proANP) in the evaluation of patients with T2D.

Methods

We prospectively evaluated the risk of incident cardiovascular (CV) events in outpatients with T2D (n = 806, mean ± standard deviation age 64 ± 10 years, 65% male, median [interquartile range] duration of diabetes 12 [6–17] years, 17.5% with symptomatic HFpEF) according to MR-proANP levels and stratified according to HF-status including further stratification according to a prespecified cut-off level of MR-proANP.

Results

A total of 126 CV events occurred (median follow-up 4.8 [4.1–5.3] years). An elevated MR-proANP, with a cut-off of 60 pmol/l or as a continuous variable, was associated with incident CV events (p < 0.001). Compared to patients without HF, patients with HFpEF and high MR-proANP (≥ 60 pmol/l; median 124 [89–202] pmol/l) and patients with HF and reduced ejection fraction (HFrEF) had a higher risk of CV events (multivariable model; hazard ratio (HR) 2.56 [95% CI 1.64–4.00] and 3.32 [1.64–6.74], respectively). Conversely, patients with HFpEF and low MR-proANP (< 60 pmol/l; median 46 [32–56] pmol/l) did not have an increased risk (HR 2.18 [0.78–6.14]).

Conclusions

Patients with T2D and HFpEF with high MR-proANP levels had an increased risk for CV events compared to patients with HFpEF without elevated MR-proANP and compared to patients without HF, supporting the use of MR-proANP in the definition of HFpEF from a prognostic point-of-view.

Predictive value of echocardiography in Type 2 diabetes

AIMS

Echocardiography is suggested in the diagnostic work-up of patients with Type 2 diabetes (T2D). We investigated which echocardiographic parameters that best predicted cardiovascular disease (CVD) and whether this was persistent in both genders in a large cohort of outpatients with T2D.

METHODS AND RESULTS

We performed comprehensive echocardiography in 933 patients with T2D followed at specialized out-patients clinics in Copenhagen, Denmark. Follow-up was performed using national registries and included admission with future CVD events and non-CVD death as competing risk. Median follow-up was 4.8 years and 138 CVD events occurred. In univariable and multivariable analyses, a wide range of structural, diastolic, and systolic measurements predicted CVD including mean E/e' [hazard ratio (HR) 1.06, 95% confidence interval: (1.03-1.10), P < 0.001, C-statistics 0.74 (0.70-0.78)] and global longitudinal strain (GLS) [1.10 (1.01-1.20), P = 0.03, C-statistics 0.73 (0.69-0.77)]. However, this was modified by gender. In men, mean E/e' remained the strongest predictor in multivariable analyses and performed best measured by highest C-statistics [HR 1.15, 95% confidence interval: (1.08-1.21), P < 0.001, C-statistics 0.75 (0.71-0.80)] whereas in women this was GLS [1.39 (1.14-1.70), P = 0.001, C-statistics 0.79 (0.70-0.87)]. These findings persisted when excluding patients with known heart disease and when regarding all-cause mortality as a competing risk.

CONCLUSION

A range of echocardiographic parameters predicted CVD in patients with Type 2 diabetes, however, in multivariable analyses, mean E/e' was the strongest predictor and had the highest model performance. Importantly, this study identifies a hitherto undescribed gender interaction as mean E/e' performed best in men, whereas in women this was GLS.

Sex differences in the association between myocardial function and prognosis in type 1 diabetes without known heart disease: the Thousand & 1 Study

AIMS

In type 1 diabetes mellitus (T1DM), recent findings suggest that women have a greater excess risk of cardiovascular diseases (CVDs) compared to men. Impaired diastolic function is a common feature in T1DM. We investigated the association between myocardial function by echocardiography and outcomes in T1DM males and females without known heart disease.

METHODS AND RESULTS

A prospective cohort of individuals with T1DM without known heart disease from the outpatient clinic of Steno Diabetes Center Copenhagen. Follow-up was performed through Danish national registers. Outcomes, major adverse cardiovascular events (MACE) and all-cause mortality, were investigated. A total of 1079 participants (mean age: 49.6 ± 14.5 years, 52.6% male, mean duration of diabetes 25.8 ± 14.6 years) were included in the study. During follow-up (median 6.3 years, interquartile range 5.7-6.9), 142 (13.2%) experienced MACE and 63 (5.8%) died. Gender modified the relationship between E/e' and both MACE and all-cause mortality (P = 0.016 and 0.007, respectively). In females, after multivariable adjustment, both E/e' and global longitudinal strain (GLS) were significantly associated with MACE [E/e': hazard ratio (HR) 1.15 confidence interval (CI) 95%: 1.07-1.24, per 1unit increase; and GLS: HR 1.19 CI 95%: 1.04-1.35, per 1% decrease] and with all-cause mortality (E/e': HR 1.26 CI 95%: 1.11-1.44; and GLS: HR 1.27 CI 95%: 1.03-1.56). In males, the association between E/e' and GLS and outcomes did not reach statistical significance.

CONCLUSION

In female individuals with T1DM both E/e' and GLS provided independent prognostic information, whereas the associations were not significant in males. These results suggest that T1DM affects myocardial function differently in males and females, which may be related to the observed sex difference in CVD risk in T1DM.

Lipid Biomarkers as Predictors of Diastolic Dysfunction in Diabetes with Poor Glycemic Control

Uncontrolled type-1 diabetes (T1DM) can lead to dyslipidaemia and albuminuria, which may promote cardiovascular injuries. However, some lipidemic factors could be useful in predicting cardiac dysfunction. Seventy-eight adolescents under insulin treatment due to a 6-year history of T1DM and were retrospectively examined. Glycemia, lipidemia, and albuminuria were measured in addition to development of cardiovascular abnormalities Both girls and boys showed higher HbA1c and fasting blood glucose and 27.1% females and 33.3% males exhibited microalbuminuria though their plasma levels of total cholesterol (TC), triglycerides (TG), and low-density lipoproteins (LDL) and high-density lipoproteins (HDL lipoproteins were in the normal range. They exhibited a preserved systolic function, but 50% of females and 66.6% of males had developed diastolic failures. Interestingly, girls with diastolic dysfunction showed significantly lower concentrations of HDL and higher TC/HDL and TG/HDL ratios. In fact, low HDL levels (OR 0.93; 95% CI 0.88-0.99; p = 0.029) and high TC/HDL (OR 2.55; 95% CI 1.9-5.45; p = 0.016) and TG/HDL (OR 2.74; 95% CI 1.12-6.71; p = 0.028) ratios associated with the development of diastolic complications. The cut-off values for HDL, TC/HDL, and TG/HDL were 49 mg/dL, 3.0 and 1.85, respectively. HDL and TC/HDL and TG/HDL ratios may be useful for predicting diastolic dysfunction in girls with uncontrolled T1DM.

Cardiac Magnetic Resonance Myocardial Feature Tracking for Optimized Risk Assessment After Acute Myocardial Infarction in Patients With Type 2 Diabetes

Type 2 diabetes predicts outcome following acute myocardial infarction (AMI). Since underlying mechanics are incompletely understood, we investigated left ventricular (LV) and left atrial (LA) pathophysiological changes and their prognostic implications using cardiovascular magnetic resonance (CMR). Consecutive patients (N = 1,147; n = 265 with diabetes, n = 882 without diabetes) underwent CMR 3 days after AMI. Analyses included LV ejection fraction (LVEF); global longitudinal strain (GLS) and circumferential and radial strains; LA reservoir, conduit, and booster pump strains; and infarct size, edema, and microvascular obstruction. Predefined end points were major adverse cardiovascular events (MACE) within 12 months. Patients with diabetes had impaired LA reservoir (19.8% vs. 21.2%, P < 0.01) and conduit (7.6% vs. 9.0%, P < 0.01) strains but not ventricular function or myocardial damage. They were at higher risk of MACE than patients without diabetes (10.2% vs. 5.8%, P < 0.01), with most MACE occurring in patients with LVEF ≥35%. While LVEF (P = 0.045) and atrial reservoir strain (P = 0.024) were independent predictors of MACE in patients without diabetes, GLS was in patients with diabetes (P = 0.010). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with MACE. In conclusion, in patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above that of LVEF.

Cardioprotective effects of melatonin: Focusing on its roles against diabetic cardiomyopathy

Melatonin is a pineal-produced indole known for its anti-aging, antiapoptotic and antioxidant properties. In past decades, the protective potentials of melatonin for cardiovascular diseases, such as atherosclerosis and myocardial infarction, have been widely revealed, triggering more investigations focused on other cardioprotective effects of melatonin. Recently, the roles of melatonin in diabetic cardiomyopathy (DCM) have attracted increased attention. In this regard, researchers found that melatonin attenuated cardiac fibrosis and hypertrophy, thus interrupting the development of DCM. Retinoid-related orphan receptor α is a key melatonin receptor that contributed to the cardioprotective effect of melatonin in hearts with DCM. For the downstream mechanisms, the inhibition of mammalian STE20-like kinase 1 plays a pivotal role, which exerts antiapoptotic and proautophagic effects, thus enhancing cardiac tolerance in high-glucose conditions. In addition, other signalling mechanisms, such as sirtuin-1/peroxisome proliferator-activated receptor gamma-coactivator alpha and endoplasmic reticulum-related signalling, are also involved in the protective effects of melatonin on cardiomyocytes under diabetic conditions. This review will focus on the protective signalling mechanisms regulated by melatonin and provide a better understanding of the therapeutic applications of melatonin signalling in DCM.

Resveratrol and Diabetic Cardiomyopathy: Focusing on the Protective Signaling Mechanisms

Diabetic cardiomyopathy (DCM) is a common cardiovascular complication of diabetic mellitus that is characterized by diastolic disorder in the early stage and clinical heart failure in the later stage. Presently, DCM is considered one of the major causes of death in diabetic patients. Resveratrol (RSV), a naturally occurring stilbene, is widely reported as a cardioprotective substance in many heart diseases. Thus far, the specific roles of RSV in DCM prevention and treatment have attracted great attention. Here, we discuss the roles of RSV in DCM by focusing its downstream targets from both in vivo and in vitro studies. Among such targets, Sirtuins 1/3 and AMP-activated kinase have been identified as key mediators that induce cardioprotection during hyperglycemia. In addition, many other signaling molecules (e.g., forkhead box-O3a and extracellular regulated protein kinases) are also regulated in the presence of RSV and exert beneficial effects such as opposing oxidative stress, inflammation, and apoptosis in cardiomyocytes exposed to high-glucose conditions. The beneficial potential of an RSV/stem cell cotherapy is also reviewed as a promising therapeutic strategy for preventing the development of DCM.

Myocardial Changes in Diabetic and Nondiabetic Nonhuman Primates

Diabetic human patients have increased risk of heart failure compared to healthy subjects. The underlying mechanisms for this are not fully understood, and to help develop improved treatment strategies, well-characterized animal models are essential. To investigate cardiac dysfunction in diabetes, this study evaluated myocardial changes in 10 aging rhesus monkeys with and without diabetes. Based on evaluation of plasma glycosylated hemoglobin and glucose, 7 of 10 rhesus macaques had diabetes for a minimum of 11 months, while 3 of 10 were categorized as nondiabetic. A detailed histological examination of formalin-fixed left ventricular myocardial samples was followed by a semiquantitative evaluation of myocardial fibrosis and fat infiltration; digital quantifications of myocardial collagen, lipofuscin, and nuclear area fractions; and measurements of cardiomyocyte diameter. Histological myocardial evaluation revealed the presence of lipofuscin; large nuclei; interstitial, replacement, and vascular fibrosis; adipocyte infiltration; and vacuolar degeneration with atrophy of cardiomyocytes and fibrosis. However, there were no differences between groups for semiquantitative fat infiltration, fibrosis, cardiomyocyte size, collagen, or nuclear and lipofuscin area fraction. Lipofuscin area fraction correlated with plasma insulin, triglyceride, total cholesterol, and high-density lipoprotein cholesterol concentrations. In conclusion, myocardial pathological changes were found in left ventricular myocardium in aged rhesus macaques, independent of the stage of diabetes. The duration of diabetes might have been too short to cause differences between groups.

Investigation of early signs of systolic and diastolic dysfunction among persons with type 1 diabetes

Background

Persons with type 1 diabetes have a higher risk to develop heart failure than the general population, and the mechanism behind the increased risk is unclear. In epidemiological studies with hospitalisation for heart failure as endpoint HbA1c, body mass index and decreased kidney function are significant risk factors, but it is unclear how these risk factors influence the development of heart failure.

Methods

In this study, we investigated early signs of systolic and diastolic dysfunction with transthoracic echocardiography. Statistical analysis on correlation of risk factors and early signs of diastolic and systolic dysfunction was made.

Results

In this study population of 287 persons with type 1 diabetes, 160 were men and 127 were women with a mean age of 53.8 (SD 11.6) years and a mean diabetes duration of 36.2 (SD 13.5) years. There were 23 (8.2%) persons who fulfilled the definition of systolic dysfunction (ejection fraction <50% or regional wall motion abnormalities) and 24 persons (9%) the definition for diastolic dysfunction. When comparing the groups with either systolic or diastolic dysfunction to the rest of the population, the only significant risk factor was age in both groups and previous myocardial infarction in the systolic group.

Conclusion

In our study population with type 1 diabetes, we found signs of diastolic dysfunction in 9% and systolic dysfunction in 8.2%. Compared with published data from the general population, this rate is somewhat higher in a younger population. Only age was a significant risk factor in the study.

Echocardiography improves prediction of major adverse cardiovascular events in a population with type 1 diabetes and without known heart disease: the Thousand & 1 Study

AIMS/HYPOTHESIS

Cardiovascular disease is the most common comorbidity in type 1 diabetes. However, current guidelines do not include routine assessment of myocardial function. We investigated whether echocardiography provides incremental prognostic information in individuals with type 1 diabetes without known heart disease.

METHODS

A prospective cohort of individuals with type 1 diabetes without known heart disease was recruited from the outpatient clinic. Follow-up was performed through Danish national registers. The association of echocardiography with major adverse cardiovascular events (MACE) and the incremental prognostic value when added to the clinical Steno T1D Risk Engine were examined.

RESULTS

A total of 1093 individuals were included: median (interquartile range) age 50.2 (39.2-60.3) years and HbA_1c 65 (56-74) mmol/mol; 53% men; and mean (SD) BMI 25.5 (3.9) kg/m² and diabetes duration 25.8 (14.6) years. During 7.5 years of follow-up, 145 (13.3%) experienced MACE. Echocardiography significantly and independently predicted MACE: left ventricular ejection fraction (LVEF) <45% (n = 18) vs ≥45% (n = 1075), HR (95% CI) 3.93 (1.91, 8.08), p < 0.001; impaired global longitudinal strain (GLS), 1.65 (1.17, 2.34) (n = 263), p = 0.005; diastolic mitral early velocity (E)/early diastolic tissue Doppler velocity (e') <8 (n = 723) vs E/e' 8-12 (n = 285), 1.59 (1.04, 2.42), p = 0.031; and E/e' <8 vs E/e' ≥12 (n = 85), 2.30 (1.33, 3.97), p = 0.003. In individuals with preserved LVEF (n = 1075), estimates for impaired GLS were 1.49 (1.04, 2.15), p = 0.032; E/e' <8 vs E/e' 8-12, 1.61 (1.04, 2.49), p = 0.033; and E/e' <8 vs E/e' ≥12, 2.49 (1.41, 4.37), p = 0.001. Adding echocardiographic variables to the Steno T1D Risk Engine significantly improved risk prediction: Harrell's C statistic, 0.791 (0.757, 0.824) vs 0.780 (0.746, 0.815), p = 0.027; and net reclassification index, 52%, p < 0.001.

CONCLUSIONS/INTERPRETATION

In individuals with type 1 diabetes without known heart disease, echocardiography significantly improves risk prediction over and above guideline-recommended clinical risk factors alone and could have a role in clinical care.

Burden of Uncontrolled Metabolic Risk Factors and Left Ventricular Structure and Function in Patients With Type 2 Diabetes Mellitus

Background Type 2 diabetes mellitus is closely associated with metabolic risk factors that all contribute to impairment of the left ventricle. The implications of having type 2 diabetes mellitus with well-controlled metabolic risk factors compared to an increasing burden of uncontrolled metabolic risk factors on left ventricular structure and function are not known. Methods and Results We compared patients with type 2 diabetes mellitus (n=751) with different degrees of uncontrolled metabolic risk factors present with a control group of individuals without present uncontrolled metabolic risk factors as recommended by the World Health Organization (n=80). In patients with well-controlled metabolic risk factors, only diastolic but neither structural nor systolic measures were impaired compared to the control group: the (early diastolic mitral inflow velocity)/(atrial diastolic mitral inflow velocity) ratio (median 0.94 [interquartile range 0.80, 1.08] versus 1.11 [0.85, 1.38], P<0.001), lateral early diastolic myocardial velocity at the level of the mitral annulus (mean 9.6 m/s [SD 2.5] versus 10.8 [3.5], P<0.001) and lateral (early diastolic mitral inflow velocity)/(early diastolic myocardial velocity at the level of the mitral annulus) (7.7 [6.5, 10.2] versus 6.3 [4.9, 7.8], P<0.001). With an increasing burden of uncontrolled metabolic risk factors, there were increased left ventricular mass index and wall thicknesses and impaired systolic function measured as global longitudinal strain: control group -15.9 (2.0); 0 uncontrolled risk factors -15.3 (2.4); 1 to 2 -14.6 (2.8); and ≥3 -14.0 (2.8), P<0.001. Within the diabetes mellitus group, there were uni- and multivariable associations of left ventricular measures and systolic blood pressure, body mass index, hemoglobin A_1c, and HDL -cholesterol. Conclusions In patients with type 2 diabetes mellitus, having well-controlled metabolic risk factors was associated with only left ventricular diastolic impairment but not with either structural or even subtle measures of systolic function. Increasing burden of uncontrolled metabolic risk factors was associated with structural and functional impairments.

Making sense of subclinical cardiac alterations in patients with diabetes

Patients with diabetes are prone to develop a distinct primary myocardial condition, diabetic cardiomyopathy, placing them at an increased risk for heart failure (1-3). This occurs independently of hypertension, coronary artery disease, and other established causes of heart failure. Pertinent findings include increased mass, concentric changes, and diastolic dysfunction of the left ventricle (4,5). Such adverse remodeling is common among patients with diabetes and appears to be strongly associated with its duration, suggesting a role for persistent metabolic stress (6-8). However, which exact components of the diabetic syndrome determine these cardiac alterations is not clear. Moreover, most studies have investigated patients with type 2 diabetes, and it is uncertain whether patients with type 1 diabetes experience similar myocardial changes. Continue reading full text in the preliminary PDF version.

Changes in Cardiac Morphology and Function in Individuals With Diabetes Mellitus: The UK Biobank Cardiovascular Magnetic Resonance Substudy

BACKGROUND

Diabetes mellitus (DM) is associated with increased risk of cardiovascular disease. Detection of early cardiac changes before manifest disease develops is important. We investigated early alterations in cardiac structure and function associated with DM using cardiovascular magnetic resonance imaging.

METHODS

Participants from the UK Biobank Cardiovascular Magnetic Resonance Substudy, a community cohort study, without known cardiovascular disease and left ventricular ejection fraction ≥50% were included. Multivariable linear regression models were performed. The investigators were blinded to DM status.

RESULTS

A total of 3984 individuals, 45% men, (mean [SD]) age 61.3 (7.5) years, hereof 143 individuals (3.6%) with DM. There was no difference in left ventricular (LV) ejection fraction (DM versus no DM; coefficient [95% CI]: -0.86% [-1.8 to 0.5]; P=0.065), LV mass (-0.13 g/m2 [-1.6 to 1.3], P=0.86), or right ventricular ejection fraction (-0.23% [-1.2 to 0.8], P=0.65). However, both LV and right ventricular volumes were significantly smaller in DM, (LV end-diastolic volume/m2: -3.46 mL/m2 [-5.8 to -1.2], P=0.003, right ventricular end-diastolic volume/m2: -4.2 mL/m2 [-6.8 to -1.7], P=0.001, LV stroke volume/m2: -3.0 mL/m2 [-4.5 to -1.5], P<0.001; right ventricular stroke volume/m2: -3.8 mL/m2 [-6.5 to -1.1], P=0.005), LV mass/volume: 0.026 (0.01 to 0.04) g/mL, P=0.006. Both left atrial and right atrial emptying fraction were lower in DM (right atrial emptying fraction: -6.2% [-10.2 to -2.1], P=0.003; left atrial emptying fraction:-3.5% [-6.9 to -0.1], P=0.043). LV global circumferential strain was impaired in DM (coefficient [95% CI]: 0.38% [0.01 to 0.7], P=0.045).

CONCLUSIONS

In a low-risk general population without known cardiovascular disease and with preserved LV ejection fraction, DM is associated with early changes in all 4 cardiac chambers. These findings suggest that diabetic cardiomyopathy is not a regional condition of the LV but affects the heart globally.

Epicardial adipose tissue predicts incident cardiovascular disease and mortality in patients with type 2 diabetes

Background

Cardiac fat is a cardiovascular biomarker but its importance in patients with type 2 diabetes is not clear. The aim was to evaluate the predictive potential of epicardial (EAT), pericardial (PAT) and total cardiac (CAT) fat in type 2 diabetes and elucidate sex differences.

Methods

EAT and PAT were measured by echocardiography in 1030 patients with type 2 diabetes. Follow-up was performed through national registries. The end-point was the composite of incident cardiovascular disease (CVD) and all-cause mortality. Analyses were unadjusted (model 1), adjusted for age and sex (model 2), plus systolic blood pressure, body mass index (BMI), low-density lipoprotein (LDL), smoking, diabetes duration and glycated hemoglobin (HbA_1c) (model 3).

Results

Median follow-up was 4.7 years and 248 patients (191 men vs. 57 women) experienced the composite end-point. Patients with high EAT (> median level) had increased risk of the composite end-point in model 1 [Hazard ratio (HR): 1.46 (1.13; 1.88), p = 0.004], model 2 [HR: 1.31 (1.01; 1.69), p = 0.038], and borderline in model 3 [HR: 1.32 (0.99; 1.77), p = 0.058]. For men, but not women, high EAT was associated with a 41% increased risk of CVD and mortality in model 3 (p = 0.041). Net reclassification index improved when high EAT was added to model 3 (19.6%, p = 0.035). PAT or CAT were not associated with the end-point.

Conclusion

High levels of EAT were associated with the composite of incident CVD and mortality in patients with type 2 diabetes, particularly in men, after adjusting for CVD risk factors. EAT modestly improved risk prediction over CVD risk factors.

Epicardial and pericardial adipose tissues are associated with reduced diastolic and systolic function in type 2 diabetes

The aim of this study was to investigate the association of epicardial (EAT) and pericardial (PAT) adipose tissues with myocardial function in type 2 diabetes (T2D). EAT and PAT were measured by ultrasound in 770 patients with T2D and 234 age- and sex-matched non-diabetic controls. Echocardiography was performed, including tissue Doppler imaging and 2D speckle tracking. Patients with T2D versus controls had increased EAT (4.6 ± 1.8 mm vs. 3.4 ± 1.2 mm, P < 0.0001) and PAT (6.3 ± 2.8 mm vs. 5.3 ± 2.4 mm, P < 0.0001). EAT and PAT were associated with structural cardiac measures both in T2D patients and controls (all P < 0.043), but only in T2D patients with functional measures: PAT was associated with impaired global longitudinal strain [beta coefficient (SE)] [0.11% (0.04), P = 0.002], while EAT was associated with reduced diastolic function by lateral early diastolic myocardial velocity (e'_lat ) [-0.31 (0.05) cm/s, P = 0.001], mitral inflow velocities: peak early (E)/peak atrial (A) ratio [-0.02 (0.01), P = 0.001] and lateral E/e'_lat [0.36 (0.10), P < 0.001]. However, no interaction was found between diabetes status and PAT (P = 0.75) or EAT (P = 0.45). Adipose tissue in intimate relation to the myocardium is higher in patients with T2D versus controls and is associated with functional myocardial measures in T2D.

Predictors of early cardiac changes in patients with type 1 diabetes mellitus: An echocardiography-based study

In patients with type 1 diabetes mellitus (T1DM) imaging studies have demonstrated an increased prevalence of left ventricular diastolic dysfunction and increased left ventricular mass (LVM) unrelated to arterial hypertension and ischemic heart disease. The aim of our study was to identify potential predictors of early subclinical changes in cardiac chamber size and function in such patients. Sixty-one middle-aged asymptomatic normotensive patients with T1DM were included in the study. Conventional and tissue Doppler echocardiography was performed and fasting serum levels of glucose, glycated hemoglobin (HbA1c), lipids, and creatinine were measured. We found moderate bivariate correlations of body mass index (BMI) with left atrial volume (r = 0.47, p < 0.01), LVM (r = 0.42, p < 0.01), left ventricular relative wall thickness (r = 0.32, p = 0.01), and all observed parameters of diastolic function of both ventricles. The five-year average value of HbA1c weakly correlated with the Doppler index of left ventricular filling pressure E/e´sept (r = 0.27, p = 0.04). We found no significant association of diabetes duration, five-year trend of HbA1c, serum lipids, and glomerular filtration rate with cardiac structure and function. After adjusting for other parameters, BMI remained significantly associated with left atrial volume, LVM as well as with the transmitral Doppler ratio E/A. In our study, BMI was the only observed parameter significantly associated with subclinical structural and functional cardiac changes in the asymptomatic middle-aged patients with T1DM.

Cardiac ventricular sizes are reduced in patients with long-term, normoalbuminuric type 1 diabetes compared to the non-diabetic background population

AIMS

Type 1 diabetes entails increased cardiovascular morbidity and cardiac chamber sizes are associated with cardiovascular disease. The aim of this study was to compare cardiac chamber sizes in normoalbuminuric persons with type 1 diabetes to a background population without diabetes.

METHODS

In a cross-sectional study, we examined 71 normoalbuminuric persons with long-term type 1 diabetes without known cardiovascular disease using cardiac multi-detector computed tomography. Cardiac chamber sizes and left ventricular remodelling were compared to persons without diabetes from the Copenhagen General Population Study.

RESULTS

Participants were median (interquartile range) 54 (48-60) (type 1 diabetes) and 57 (50-64) (without diabetes) years old and 59% were men (both groups). Participants with type 1 diabetes had smaller left ventricular mass (-3.5 g/m², 95% confidence interval -5.8 to -1.3) and left (-4.0 mL/m², 95% confidence interval -6.9 to -1.0) and right (-11.7 mL/m², 95% confidence interval -15.4 to -7.9) ventricular volumes in multivariable analyses (adjusted for age, sex, body composition, blood pressure and antihypertensive medication), but no differences in atrial volumes.

CONCLUSION

Persons with long-term type 1 diabetes had smaller left ventricular mass and biventricular volumes, yet similar atrial sizes, compared to a background population without diabetes. These findings may reflect subclinical development of diabetic cardiomyopathy.

An echocardiographic substrate for dyspnea identifies high risk patients with type 2 diabetes

BACKGROUND

Dyspnea is a common clinical challenge in patients with type 2 diabetes and may be a sign of heart failure (HF). We sought to evaluate the predictive value dyspnea with and without an echocardiographic substrate in patients with type 2 diabetes without known heart disease.

METHODS

A total of 724 patients with type 2 diabetes followed at specialized clinics participated in this prospective cohort study. Clinical evaluation, comprehensive echocardiography and follow-up through national registers were performed. An echocardiographic substrate was either left ventricular hypertrophy, increased left atrial size, E/e' > 15, or LV ejection fraction<50%. The end-points were cardiovascular (CVD) events and all-cause mortality.

RESULTS

Median follow-up was 4.8 years [Interquartile range: 4.1, 5.3] for CVD event and 77 patients suffered a CVD event. Dyspnea was significantly associated with CVD event: Hazard ratio (HR): 1.58 (95% confidence interval: 1.01-2.48), p = 0.04. Stratifying by evidence of echocardiographic substrate revealed high risk individuals: CVD event: 0.71 (0.35-1.46), p = NS in patients with dyspnea and no echocardiographic substrate and 2.85 (1.74-4.67), p < 0.001 in patients with dyspnea with echocardiographic substrate). This pattern was similar in multivariable analyses. Also, C-statistics improved from 0.66 (0.60-0.72) to 0.69 (0.63-0.75), p < 0.001 and net reclassification index was 27.5%(5.0-50.0), p = 0.01 for CVD event. The results were similar for all-cause mortality except dyspnea was only a borderline significant predictor.

CONCLUSION

In patients with type 2 diabetes complaining of dyspnea, identifying an echocardiographic substrate - thus indicating patients with HF - accurately stratifies patients with increased risk of CV events and all-cause mortality.

Resting heart rate and relation to disease and longevity: past, present and future

Assessment of heart rate has been used for millennia as a marker of health. Several studies have indicated that low resting heart rate (RHR) is associated with health and longevity, and conversely, a high resting heart to be associated with disease and adverse events. Longitudinal studies have shown a clear association between increase in heart rate over time and adverse events. RHR is a fundamental clinical characteristic and several trials have assessed the effectiveness of heart rate lowering medication, for instance beta-blockers and selective sinus node inhibition. Advances in technology have provided new insights into genetic factors related to RHR as well as insights into whether elevated RHR is a risk factor or risk marker. Recent animal research has suggested that heart rate lowering with sinus node inhibition is associated with increased lifespan. Furthermore, genome-wide association studies in the general population using Mendelian randomization have demonstrated a causal link between heart rate at rest and longevity. Furthermore, the development in personal digital devices such as mobile phones, fitness trackers and eHealth applications has made heart rate information and knowledge in this field as important as ever for the public as well as the clinicians. It should therefore be expected that clinicians and health care providers will be met by relevant questions and need of advice regarding heart rate information from patients and the public. The present review provides an overview of the current knowledge in the field of heart rate and health.

Left ventricular remodelling and cardiac chamber sizes in long-term, normoalbuminuric type 1 diabetes patients with and without cardiovascular autonomic neuropathy

AIMS

Type 1 diabetes is associated with increased cardiovascular (CV) morbidity and mortality, and cardiovascular autonomic neuropathy (CAN) is an important CV risk factor. The study aimed to explore associations between CAN and altered cardiac chamber sizes in persons with type 1 diabetes.

METHODS

This was a cross-sectional study of 71 asymptomatic, normoalbuminuric participants with long-term type 1 diabetes (39 with CAN, determined by >1 abnormal autonomic function test) examined with cardiac multi detector computed tomography scans, which allowed measurements of left ventricular mass and all four cardiac chamber volumes. Cardiac chambers were indexed according to body surface area (ml/m² or g/m²).

RESULTS

Persons with and without CAN had mean ± SD age of 57 ± 7 and 50 ± 8 years (p < 0.001) and diabetes duration of 36 ± 11 and 32 ± 9 years (p < 0.05), respectively. Increasing autonomic dysfunction, evaluated by decrease in heart rate variability during deep breathing (in beats per minute), was associated with larger right (-0.5, 95% CI -1.0 to -0.0, p < 0.05) and trend towards larger left (-0.4, 95% CI -0.8-0.0, p < 0.1) ventricular volumes in multivariable linear regression.

CONCLUSIONS

Our results suggest that impaired autonomic function may be associated with modest enlargement of ventricular volumes; this might be an early sign of progression towards heart failure.

Mitochondrial NAD+/NADH Redox State and Diabetic Cardiomyopathy

Significance: Diabetic cardiomyopathy (DCM) is a frequent complication occurring even in well-controlled asymptomatic diabetic patients, and it may advance to heart failure (HF). Recent Advances: The diabetic heart is characterized by a state of "metabolic rigidity" involving enhanced rates of fatty acid uptake and mitochondrial oxidation as the predominant energy source, and it exhibits mitochondrial electron transport chain defects. These alterations promote redox state changes evidenced by a decreased NAD⁺/NADH ratio associated with an increase in acetyl-CoA/CoA ratio. NAD⁺ is a co-substrate for deacetylases, sirtuins, and a critical molecule in metabolism and redox signaling; whereas acetyl-CoA promotes protein lysine acetylation, affecting mitochondrial integrity and causing epigenetic changes. Critical Issues: DCM lacks specific therapies with treatment only in later disease stages using standard, palliative HF interventions. Traditional therapy targeting neurohormonal signaling and hemodynamics failed to improve mortality rates. Though mitochondrial redox state changes occur in the heart with obesity and diabetes, how the mitochondrial NAD⁺/NADH redox couple connects the remodeled energy metabolism with mitochondrial and cytosolic antioxidant defense and nuclear epigenetic changes remains to be determined. Mitochondrial therapies targeting the mitochondrial NAD⁺/NADH redox ratio may alleviate cardiac dysfunction. Future Directions: Specific therapies must be supported by an optimal understanding of changes in mitochondrial redox state and how it influences other cellular compartments; this field has begun to surface as a therapeutic target for the diabetic heart. We propose an approach based on an alternate mitochondrial electron transport that normalizes the mitochondrial redox state and improves cardiac function in diabetes.

Cardiac repolarization and depolarization in people with Type 1 diabetes with normal ejection fraction and without known heart disease: a case-control study

AIMS

To investigate depolarization and repolarization durations in people with Type 1 diabetes, including the relationship to age.

METHODS

855 persons with Type 1 diabetes without known heart disease were included and matched with 1710 participants from a general population study. Clinical examinations, questionnaires and biochemistry were assessed. A 10-second 12-lead ECG was performed and analysed digitally.

RESULTS

QT_c was longer in people with Type 1 diabetes compared to controls (414±16 vs. 411±19 ms, P <0.001), and particularly so in young people with Type 1 diabetes. The fully adjusted increase was 13.8 ms (95% confidence interval (CI): 8.6-19.0 ms, P <0.001) at age 20 years and 3.4 ms (CI: 1.5-5.3 ms, P<0.001) at age 40 years. The rate-corrected QRS_c was increased in people with Type 1 diabetes (97±11 vs. 95±11 ms, P <0.001) and was age-independent (P =0.5). JT_c was increased in the young people with Type 1 diabetes (10.7 ms (CI: 5.4-16.0 ms, P <0.001) at age 20 years), but not in older people with Type 1 diabetes (interaction age-diabetes, P <0.01).

CONCLUSIONS

For people with Type 1 diabetes, cardiac depolarization is increased at all ages, whereas repolarization is increased only relatively in young people with Type 1 diabetes. Hence, young people with Type 1 diabetes may be more prone to ventricular arrhythmias. The findings contribute to the understanding of sudden cardiac death in young people with Type 1 diabetes.

Diabetic Cardiomyopathy: Impact of Biological Sex on Disease Development and Molecular Signatures

Diabetic cardiomyopathy refers to a unique set of heart-specific pathological variables induced by hyperglycemia and insulin resistance. Given that cardiovascular disease (CVD) is the leading cause of death in the world, and type 2 diabetes incidence continues to rise, understanding the complex interplay between these two morbidities and developing novel therapeutic strategies is vital. Two hallmark characteristics specific to diabetic cardiomyopathy are diastolic dysfunction and cardiac structural mal-adaptations, arising from cardiac cellular responses to the complex toxicity induced by hyperglycemia with or without hyperinsulinemia. While type 2 diabetes is more prevalent in men compared to women, cardiovascular risk is higher in diabetic women than in diabetic men, suggesting that diabetic women take a steeper path to cardiomyopathy and heart failure. Accumulating evidence from randomized clinical trials indicate that although pre-menopausal women have lower risk of CVDs, compared to age-matched men, this advantage is lost in diabetic pre-menopausal women, which suggests estrogen availability does not protect from increased cardiovascular risk. Notably, few human studies have assessed molecular and cellular mechanisms regarding similarities and differences in the progression of diabetic cardiomyopathy in men versus women. Additionally, most pre-clinical rodent studies fail to include female animals, leaving a void in available data to truly understand the impact of biological sex differences in diabetes-induced dysfunction of cardiovascular cells. Elegant reviews in the past have discussed in detail the roles of estrogen-mediated signaling in cardiovascular protection, sex differences associated with telomerase activity in the heart, and cardiac responses to exercise. In this review, we focus on the emerging cellular and molecular markers that define sex differences in diabetic cardiomyopathy based on the recent clinical and pre-clinical evidence. We also discuss miR-208a, MED13, and AT2R, which may provide new therapeutic targets with hopes to develop novel treatment paradigms to treat diabetic cardiomyopathy uniquely between men and women.

Arterial-ventricular coupling in type 1 diabetes: arterial stiffness is associated with impaired global longitudinal strain in type 1 diabetes patients-the Thousand & 1 Study

AIMS

Diabetes is associated with higher arterial stiffness-an early marker of cardiovascular disease. The coupling between arterial stiffness and myocardial function is still unresolved. We investigate associations between arterial stiffness and early myocardial impairment assessed with advanced echocardiography.

METHODS

In 305 type 1 diabetes (T1D) patients without known heart disease and with normal left ventricular ejection fraction (LVEF) (biplane LVEF > 45%), we measured arterial stiffness as pulse wave velocity (PWV) and performed conventional and speckle-tracking echocardiography assessing global longitudinal strain (GLS) as a measure of systolic myocardial function. Associations between PWV and myocardial function were reported as standardized beta values from adjusted regression models including age, sex, mean arterial pressure, body mass index, HbA_1c, diabetes duration, estimated glomerular filtration rate, degree of albuminuria, total cholesterol, heart rate and smoking.

RESULTS

Patients were 54 (12) years [mean (SD)], 152 (50%) females, diabetes duration 31 (16) years, HbA_1c 65 (12) mmol/mol, LVEF 58 (5) %, GLS -18.2 (2.6) % and PWV 10.2 (3.4) m/s. There was no association between PWV and LVEF (p = 0.93). Conversely, there was a highly significant association between PWV and GLS in crude and multivariable models (standardized β-coefficient 0.25, p < 0.001 and 0.16, p = 0.036, respectively). Also, diastolic function measured as E/e' was highly associated with PWV in crude and multivariable models (standardized β-coefficient 0.43, p < 0.001 and 0.17, p = 0.016, respectively).

CONCLUSIONS

In T1D patients with normal LVEF and without known heart disease, higher arterial stiffness is independently associated with early systolic and diastolic myocardial impairment detectable by advanced echocardiography. Although unable to demonstrate causality, we display a relationship between diabetic angiopathy and diabetic cardiomyopathy (H-3-2009-139 and PROFIL-H-B-2009-056).