Changes in multidirectional LV strain in asymptomatic patients with type 2 diabetes mellitus: a 2-year follow-up study

Risk Factors for Unfavorable Glycemic Control Trajectory in Type-2 Diabetes Mellitus: A Community-based Longitudinal Study in Urbanslums of Central India

BACKGROUND

Diabetes mellitus (DM) is a chronic disease, which requires optimal glycemic control to prevent its ensuing vascular complications. Pathway to optimal glycemic control in T2DM has a complex socio-behavioral construct, especially in vulnerable populations, like slum dwellers, who have reduced health-care access and lower prioritization of health needs.

OBJECTIVE

The study aimed to map trajectories of glycemic control amongst individuals with T2DM living in urban slums and identify key determinants associated with unfavourable glycaemic trajectory.

METHODS

This study was a community-based longitudinal study conducted in an urban slum of Bhopal in Central India. Adult patients diagnosed with T2DM and on treatment for more than one year were included. All 326 eligible participants underwent a baseline interview, which captured sociodemographic, personal behavior, medication adherence, morbidity profile, treatment modality, anthropometric and biochemical measurements (HbA1c). Another 6-month follow-up interview was conducted to record anthropometric measurements, HbA1c and treatment modality. Four mixed effect logistic regression models (through theory-driven variable selections) were created with glycemic status as dependent variable and usage of insulin was considered as random effect.

RESULTS

A total of 231 (70.9%) individuals had unfavorable glycemic control trajectory (UGCT), and only 95 (29.1%) had a favorable trajectory. Individuals with UGCT were more likely to be women, with lower educational status, non-vegetarian food preference, consumed tobacco, had poor drug adherence, and were on insulin. The most parsimonious model identified female gender (2.44,1.33-4.37), tobacco use (3.80,1.92 to 7.54), and non-vegetarian food preference (2.29,1.27 to 4.13) to be associated with UGCT. Individuals with good medication adherence (0.35,0.13 to 0.95) and higher education status (0.37,0.16 to 0.86) were found to be protective in nature.

CONCLUSION

Unfavorable glycemic control trajectory seems to be an inescapable consequence in vulnerable settings. The identified predictors through this longitudinal study may offer a cue for recognizing a rational response at societal level and adopting strategy formulation thereof.

The effect of type 2 diabetes mellitus on multiple obstructive coronary artery disease

BACKGROUND

Although type 2 diabetes mellitus (T2DM) individuals easily develop three-vessel disease (3VD) coronary artery disease (CAD), there is very little information available about their left ventricle (LV) functions. The purpose of this study is to evaluate the LV function using two-dimensional speckle tracking echocardiography (2-D STE) in T2DM patients with 3VD.

METHODS

One hundred and three consecutive patients with confirmed 3VD CAD were enrolled and divided into two groups, while 53 patients with DM and 50 patients without. The control group was composed of 30 age- and sex-matched healthy individuals. All patients underwent 2-D STE and standard echocardiograms. The durations of DM and the level of HbA1c were also recorded.

RESULT

Between the 3VD-DM and 3VD-non-DM groups, normal echocardiography did not reveal any appreciable differences. However, patients with 3VD-DM had significantly lower global longitudinal strain (GLS) than those with 3VD-non-DM (15.87 ± 2.51 vs.17.56 ± 2.72, p < .05) by 2-D STE strain measurement. Besides, patients whose duration of DM excess 5 years showed significant lower GLS than those with less than 5 years duration (14.25 ± 2.31 vs. 16.65 ± 1.96, p = .007). However, there was no difference in GLS between the 3VD-DM patients with HbA1c ≥ 7% and HbA1c < 7%.

CONCLUSIONS

Compared to patients with 3VD alone, those with 3VD-DM have a lower cardiac function. In 3VD-DM patients, the duration of DM is a significant factor that contributes to cardiac function deterioration, whereas, the glucose control state has limited influence.

Cardiometabolic-based chronic disease: adiposity and dysglycemia drivers of heart failure

Heart failure (HF) is a complex clinical syndrome, associated with high rates of mortality, hospitalization, and impairment of quality of life. Obesity and type 2 diabetes are major cardiometabolic drivers, represented as distinct stages of adiposity- and dysglycemia-based chronic disease (ABCD, DBCD), respectively, and leading to cardiometabolic-based chronic disease (CMBCD). This review focuses on one aspect of the CMBCD model: how ABCD and DBCD influence genesis and progression of HF phenotypes. Specifically, the relationships of ABCD and DBCD stages with structural and functional heart disease, HF risk, and outcomes in overt HF are detailed. Also, evidence-based lifestyle, pharmacological, and procedural interventions that promote or reverse cardiac remodeling and outcomes in individuals at risk or with HF are discussed. In summary, driver-based chronic disease models for individuals at risk or with HF can expose prevention targets for more comprehensive interventions to improve clinical outcomes. Future randomized trials that investigate structured lifestyle, pharmacological, and procedural therapies specifically tailored for the CMBCD model are needed to develop personalized care plans to decrease HF susceptibility and improve outcomes.

Diabetic microvascular complications are associated with reduced global longitudinal strain independent of atherosclerotic coronary artery disease in asymptomatic patients with diabetes mellitus: a cross-sectional study

Background

Reduced left ventricular function, assessed by global longitudinal strain (GLS), is sometimes observed in asymptomatic patients with diabetes mellitus (DM) and is often present in patients with diabetes-related microvascular complications. Our aim was to assess the association between microvascular complications, coronary artery plaque burden (PB) and GLS in asymptomatic patients with DM and non-obstructive coronary artery disease (CAD).

Methods

This cross-sectional study included patients with DM without any history, symptoms or objective evidence of obstructive CAD. All patients were identified in the outpatient Clinic of Endocrinology at Odense University Hospital Svendborg. An echocardiography and a coronary computed tomography angiography were performed to assess GLS and the degree of CAD, respectively. A coronary artery stenosis < 50% was considered non-obstructive. A linear regression model was used to evaluate the impact of potential confounders on GLS with adjustment of body mass index (BMI), mean arterial pressure (MAP), microvascular complications, type of diabetes, tissue Doppler average early diastolic mitral annulus velocity (e’) and PB.

Results

Two hundred and twenty-two patients were included, of whom 172 (77%) had type 2 DM and 50 (23%) had type 1 diabetes. One hundred and eleven (50%) patients had microvascular complications. GLS decreased as the burden of microvascular complications increased (P-trend = 0.01): no microvascular complications, GLS (− 16.4 ± 2.5%), 1 microvascular complication (− 16.0 ± 2.5%) and 2–3 microvascular complications (− 14.9 ± 2.8%). The reduction in GLS remained significant after multivariable adjustment (β 0.50 [95% CI 0.11–0.88], p = 0.01). BMI (β 0.12 [95% CI 0.05–0.19]) and MAP (β 0.05 [95% CI 0.01–0.08]) were associated with reduced GLS. In addition, an increased number of microvascular complications was associated with increased PB (β 2.97 [95% CI 0.42–5.51], p = 0.02) in a univariable linear regression model, whereas there was no significant association between PB and GLS.

Conclusions

The burden of microvascular complications was associated with reduced GLS independent of other cardiovascular risk factors in asymptomatic patients with DM and non-obstructive CAD. In addition, the burden of microvascular complications was associated with increasing PB, whereas PB was not associated with GLS.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-02063-w.

Cardiovascular and systemic determinants of exercise capacity in people with type 2 diabetes mellitus

The global burden of heart failure (HF) is on the rise owing to an increasing incidence of lifestyle related diseases, predominantly type 2 diabetes mellitus (T2D). Diabetes is an independent risk factor for cardiovascular disease, and up to 75% of those with T2D develop HF in their lifetime. T2D leads to pathological alterations within the cardiovascular system, which can progress insidiously and asymptomatically in the absence of conventional risk factors. Reduced exercise tolerance is consistently reported, even in otherwise asymptomatic individuals with T2D, and is the first sign of a failing heart. Because aggressive modification of cardiovascular risk factors does not eliminate the risk of HF in T2D, it is likely that other factors play a role in the pathogenesis of HF. Early identification of individuals at risk of HF is advantageous, as it allows for modification of the reversible risk factors and early initiation of treatment with the aim of improving clinical outcomes. In this review, cardiac and extra-cardiac contributors to reduced exercise tolerance in people with T2D are explored.

Diagnostic Accuracy of Global Longitudinal Strain for Detecting Significant Coronary Artery Disease in Diabetic Patients without Regional Wall Motion Abnormality

AIMS

Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this prospective study was to assess the diagnostic accuracy of global longitudinal strain (GLS) and regional longitudinal strain (RLS) parameters at rest in comparison to stress echocardiography findings for detecting significant coronary artery disease (CAD) in patients with diabetes mellitus (DM).

METHODS

We prospectively studied echocardiographic characteristics at rest with Speckle tracking echocardiography (2D STE) measures; then stress echocardiography and coronary angiography data in 34 diabetic patients without regional wall motion abnormality (RWMA) at rest. Patients were grouped according to coronary angiography and stress echocardiography results into two groups CAD (+) vs control group CAD (-).

RESULTS

GLS at rest was lower in the CAD (+) group ((-14.2 % ± 3.1 vs -17.8 % ± 3.1 in the control group CAD (-), P=0.004). GLS at rest had the highest area under the ROC curve (AUC) (AUC 0.78, sensitivity 61%, specificity 91%,P=0.009) with the cut-off of -14.5% which is equal to predictive power of wall motion scoring index (WMSI) at peak stress to detect significant CAD (AUC=0.76 (95% CI 0.58-0.94, P= 0.016) with the cut-off value of 1.21).

CONCLUSIONS

Global longitudinal strain at rest by STE showed excellent specificity (>90%) and good sensitivity (60%) for the diagnosis of severe CAD among the diabetic population with unknown CAD. This is the first study showing that GLS at rest with cutoff value at -14.5% had good and equal diagnostic accuracy as WMSI at peak stress to detect significant CAD among the diabetic population.

The relation between left ventricular global longitudinal strain and troponin levels in patients hospitalized with COVID-19 pneumonia

Left ventricular global longitudinal strain (LVGLS) from two-dimensional speckle-tracking echocardiography (2D-STE) provides a more accurate estimation of subclinical myocardial dysfunction. In patients with COVID-19, elevated high sensitive troponin (hs-TnI) levels are frequent independent from the underlying cardiovascular disease. However, the relationship between high troponin levels and LVGLS in such patients remains unknown. We aimed to investigate the relation between troponin levels and LVGLS values in patients with COVID-19. A total of thirty-eight patients diagnosed with COVID-19 pneumonia who underwent echocardiography examination within the first week of hospital admission were enrolled in our study. Patients were divided into two groups according to their hs-TnI levels. Conventional left venticular (LV) function parameters, including ejection fraction, LV diastolic and systolic volumes were obtained and LVGLS was determined using 2D-STE. Frequency of hypertension, diabetes mellitus and current smoking were similar among groups. Compared with the patients in the negative troponin group, those in the positive troponin group were more likely to have a higher age; higher levels of D-dimer, C-reactive protein and ferritin; higher need for high-flow oxygen, invasive mechanical ventilation therapy or both; and a higher number of intensive care unit admissions. There was no statistically significant difference in LVGLS and ejection fraction values between the two groups.(− 18.5 ± 2.9, − 19.8 ± 2.8, p = 0.19; 55.2 ± 9.9, 59.5 ± 5.9, p = 0.11 respectively). Despite troponin increase is highly related to in-hospital adverse events; no relevance was found between troponin increase and LVGLS values of COVID-19 patients.

Diabetic cardiomyopathy: Pathophysiology, theories and evidence to date

The prevalence of type 2 diabetes (T2D) has increased worldwide and doubled over the last two decades. It features among the top 10 causes of mortality and morbidity in the world. Cardiovascular disease is the leading cause of complications in diabetes and within this, heart failure has been shown to be the leading cause of emergency admissions in the United Kingdom. There are many hypotheses and well-evidenced mechanisms by which diabetic cardiomyopathy as an entity develops. This review aims to give an overview of these mechanisms, with particular emphasis on metabolic inflexibility. T2D is associated with inefficient substrate utilisation, an inability to increase glucose metabolism and dependence on fatty acid oxidation within the diabetic heart resulting in mitochondrial uncoupling, glucotoxicity, lipotoxicity and initially subclinical cardiac dysfunction and finally in overt heart failure. The review also gives a concise update on developments within clinical imaging, specifically cardiac magnetic resonance studies to characterise and phenotype early cardiac dysfunction in T2D. A better understanding of the pathophysiology involved provides a platform for targeted therapy in diabetes to prevent the development of early heart failure with preserved ejection fraction.

Defining Subclinical Myocardial Dysfunction and Implications for Patients With Diabetes Mellitus and Preserved Ejection Fraction

Left ventricular (LV) global longitudinal strain (GLS) can detect subclinical myocardial systolic dysfunction in individuals with diabetes. The present study investigates the clinical usefulness and incremental net benefit of identifying subclinical myocardial systolic dysfunction in individuals with diabetes. A cohort of 397 type 2 diabetic individuals was followed up for the occurrence of all-cause mortality. Clinical and echocardiographic data of diabetic patients were assessed retrospectively. LV GLS was evaluated on transthoracic echocardiography using speckle tracking imaging. Subclinical LV systolic dysfunction was defined as LV GLS > -17.0% from 104 healthy volunteers recruited from the community. A total of 178 (44.8%) diabetic individuals had evidence of subclinical LV systolic dysfunction and 46 (11.6%) died during follow-up. The presence of subclinical LV systolic dysfunction was independently associated with all-cause mortality on follow-up (hazard ratio [HR] 2.83, 95% confidence interval [CI] 1.40 to 5.71, p = 0.004). Diabetic individuals without subclinical LV systolic dysfunction had similar survival as the general population (standardized mortality ratio 0.94, 95% CI 0.52 to 1.58). Decision curve analysis showed identification of subclinical LV systolic dysfunction and quantification of LV GLS provided an incremental net clinical benefit at risk stratifying patients for risk of death at 5 years. In conclusion, subclinical LV systolic dysfunction is independently associated with all-cause mortality in diabetic patients. Decision curve analyses suggest use of LV GLS and identification of subclinical LV systolic dysfunction is clinically useful, and provided incremental net clinical benefit for diabetic individuals.

Lower limit of normality and clinical relevance of left ventricular early diastolic strain rate for the detection of left ventricular diastolic dysfunction

Aims

The aim of the present study was to determine the lower limit of normality and the clinical relevance of left ventricular (LV) early diastolic strain rate (LVSRe) for the detection of LV diastolic dysfunction (LVDD).

Methods and results

Using 2D speckle-tracking echocardiography, we analysed 377 healthy subjects and 475 patients with risk for LVDD with preserved LV ejection fraction (LVEF). The normal range of LVSRe analysing the healthy subjects was 1.56 ± 0.28 s-1, with a lower limit of normality at 1.00 s-1. Using this cut-off, LVSRe was able to detect high rates of LV diastolic alterations (rate 71.1%), which was significantly better than using indirect diastolic parameters such as left atrial volume index (LAVI) and tricuspid regurgitation velocity (TR) (rates 22.9% and 9.1%) and similar to annular mitral parameters such as lateral and septal e' velocity (rates 70.9% and 72.4%). In line, adding LVSRe to the current evaluation of LVDD increased significantly the rate of detection of LVDD (absolute rate of increase 18.9%; rate of detection of LVDD: from 14.3% to 33.2%, P < 0.01). Regarding the clinical relevance of LVSRe, patients with abnormal LVSRe (i.e. <1.00 s-1) had significantly worse New York Heart Association functional class and symptomatic status than those with normal LVSRe. In addition, in a retrospective post hoc analysis, we found that an abnormal LVSRe had a significant association with the risk of heart failure hospitalization at 2 years (odds ratio 5.0, 95% confidence interval 1.3-18.4), which was better than using conventional diastolic parameters such as septal and lateral e' velocity, LAVI and TR velocity.

Conclusion

The findings from this multicentre study provide important data regarding the normal range of LVSRe and highlight the potential clinical relevance of using this new diastolic parameter in the detection of LVDD in patients with preserved LVEF.

Diabetic cardiomyopathy: prevalence, determinants and potential treatments

The prevalence of type 2 diabetes (T2D) has reached a pandemic scale. These patients are at a substantially elevated risk of developing cardiovascular disease, with heart failure (HF) being a leading cause of morbidity and mortality. Even in the absence of traditional risk factors, diabetes still confers up to a twofold increased risk of developing HF. This has led to identifying diabetes as an independent risk factor for HF and recognition of the distinct clinical entity, diabetic cardiomyopathy. Despite a wealth of research interest, the prevalence and determinants of diabetic cardiomyopathy remain uncertain. This limited understanding of the pathophysiology of diabetic heart disease has also hindered development of effective treatments. Tight blood-glucose and blood-pressure control have not convincingly been shown to reduce macrovascular outcomes in T2D. There is, however, emerging evidence that T2D is reversible and that the metabolic abnormalities can be reversed with weight loss. Increased aerobic exercise capacity is associated with significantly lower cardiovascular and overall mortality in diabetes. Whether such lifestyle modifications as weight loss and exercise may ameliorate the structural and functional derangements of the diabetic heart has yet to be established. In this review, the link between T2D and myocardial dysfunction is explored. Insights into the structural and functional perturbations that typify the diabetic heart are first described. This is followed by an examination of the pathophysiological mechanisms that contribute to the development of cardiovascular disease in T2D. Lastly, the current and emerging therapeutic strategies to prevent or ameliorate cardiac dysfunction in T2D are evaluated.

Cardiovascular Implications of Diabetes, Metabolic Syndrome, Thyroid Disease, and Cardio-Oncology in Women

Cardiovascular disease may be associated with several comorbidities, including diabetes mellitus, thyroid disorders, and the metabolic syndrome, which are predominantly observed in women and often starting at particular ages. In addition, common treatment options for carcinomas frequently seen in women may induce serious cardiotoxic effects. We review the scope of the problem, the pathophysiologic mechanisms involved, as well as the resulting abnormalities regarding cardiac structure and function as observed by using imaging techniques.

Temporal changes in left ventricular longitudinal strain in general population: Clinical correlates and impact on cardiac remodeling

BACKGROUND

Recent studies in patients and general population have reported the role of left ventricular (LV) longitudinal strain (LS) as an independent predictor of outcome. However, there are few data on changes in LS over time. We therefore investigated in a general population clinical correlates of temporal changes in LS. We also explored the potential correlation between temporal changes in LV volumes and LS.

METHODS AND RESULTS

We measured LV end-systolic (ESV) and end-diastolic (EDV) volumes by conventional echocardiography and LS by 2D speckle tracking in 627 participants (mean age 50.6 years, 51.4% women; 41.3% hypertensives) at baseline and after 4.7 years. For statistical analysis, we used the absolute values of LS. In stepwise regression, the magnitude of the decrease in all LV LS indexes over time was greater in men than in women (P < 0.0001). Higher baseline mean arterial pressure (MAP), a larger longitudinal increase in MAP, and stopping diuretic treatment during follow-up were related to larger decreases in LS indexes. In multivariable-adjusted analysis, we observed an inverse correlation between baseline ESV and LV LS (P ≤ 0.0017). Similarly, lower baseline LS and a larger decrease in LS over time were correlated with a lesser longitudinal decrease in ESV (P ≤ 0.0004).

CONCLUSIONS

A significant decrease in LS over time was associated with male sex, higher baseline MAP, ∆MAP, and alteration in antihypertensive treatment. We suggested an interaction between a longitudinal decrease in LV deformation and adverse cardiac remodeling, while underscoring the importance of deformation analysis based on LS assessment in patients at risk.

Short-term high-fat diet compromises myocardial function: a radial strain rate imaging study

Aim

Long-term high-fat diet (HFD) induces both cardiac remodelling and myocardial dysfunction in murine models. The aim was to assess the time course and mechanisms of metabolic and cardiac modifications induced by short-term HFD in wild-type (WT) mice.

Methods and results

Thirty-three WT mice were subjected to HFD (60% fat, n = 16) and chow diet (CD, 13% fat, n = 17). Metabolic and echocardiographic data were collected at baseline and every 5 weeks for 20 weeks. Invasive haemodynamic data and myocardial samples were collected at 5 and 20 weeks. Echocardiographic data included left ventricular (LV) diameters and thickness, and systolic function using radial strain rate (SR). Histological assessment of cardiomyocyte and adipocyte sizes, interstitial fibrosis, and apoptosis index were performed. During follow-up, body weight, and glycaemia levels were higher in HFD than in CD mice, in association with an early adipose tissue remodelling. Despite no difference between both groups in blood pressure and LV mass at 5 weeks, an early LV dysfunction was observed in HFD mice as assessed by radial SR (21 ± 0.8 vs. 27 ± 0.8 unit/s, P < 0.001) and haemodynamic assessment. During follow-up, both groups demonstrated a progressive systolic and diastolic LV dysfunction and remodelling including dilatation and hypertrophy, which were more severe in HFD mice. Compared with CD mice, the early LV impairment in HFD mice was coupled with a higher cardiomyocyte apoptosis level (0.95 vs. 0.02%, P < 0.05) associated with an interstitial fibrosis process (2.3 vs. 0.2%, P < 0.05), which worsen during follow-up.

Conclusion

The HFD promoted early metabolic and cardiac dysfunctions, and adipose and myocardial tissues remodelling.

Global Longitudinal Strain at Rest for Detection of Coronary Artery Disease in Patients without Diabetes Mellitus

Global longitudinal strain (GLS) at rest on two-dimensional speckle tracking echocardiography (2D STE) was demonstrated to help detect coronary artery disease (CAD). However, the optimal cut-off point of GLS and its diagnostic power for detecting critical CAD in non-diabetes mellitus (DM) patients are unknown. In the present study, 211 patients with suspected CAD were prospectively included, with DM patients excluded. All patients underwent echocardiography and subsequently coronary angiography within 3 days. Left ventricular (LV) GLSs were quantified by 2D STE. Territorial peak systolic longitudinal strains (TLSs) were calculated based on the perfusion territories of the 3-epicardial coronary arteries in a 17-segment LV model. Critical CAD was defined as an area stenosis ≥70% in ≥1 epicardial coronary artery (≥50% in left main coronary artery). Totally 145 patients were diagnosed as having critical CAD by coronary angiography. Significant differences were observed in all strain parameters between patients with and without critical CAD. The area under the receiver operating charcteristic (ROC) curve (AUC) for GLS in the detection of left main (LM) or threevessel CAD was 0.875 at a cut-off value of -19.05% with sensitivity of 78.1% and specificity of 72.7%, which increased to 0.926 after exclusion of apical segments (cut-off value -18.66%; sensitivity 84.4% and specificity 81.8%). The values of TLSs were significantly lower in regions supplied by stenotic arteries than in those by non-stenotic arteries. The AUC for the TLSs to identify critical stenosis of left circumflex (LCX) artery, left anterior descending (LAD) artery and right coronary artery (RCA), in order of diagnostic accuracy, was 0.818 for LCX, 0.764 for LAD and 0.723 for RCA, respectively. In conclusion, in non-DM patients with suspected CAD, GLS assessed by 2D STE is an excellent predictor for LM or three-vessel CAD with high diagnostic accuracy, and a higher cut-off point than reported before should be used. Excluding apical segments in the calculation of GLS can further improve the predictive accuracy of GLS. It is unsatisfactory for TLSs to be used to identify stenotic coronary arteries.

Early detection of left ventricular diastolic dysfunction using conventional and speckle tracking echocardiography in a large animal model of metabolic dysfunction

Left ventricular (LV) diastolic dysfunction is one of the important mechanisms responsible for symptoms in patients with heart failure. The aim of the current study was to identify parameters that may be used to detect early signs of LV diastolic dysfunction in diabetic pigs on a high fat diet, using conventional and speckle tracking echocardiography. The study population consisted of 16 healthy Göttingen minipigs and 18 minipigs with experimentally induced metabolic dysfunction. Echocardiography measurements were performed at baseline and 3-month follow-up. The ratio of peak early (E) and late filling velocity (E/A ratio) and the ratio of E and the velocity of the mitral annulus early diastolic wave (E/Em ratio) did not change significantly in both groups. Peak untwisting velocity decreased in the metabolic dysfunction group (- 30.1 ± 18.5 vs. - 23.4 ± 15.5 °/ms) but not in controls (- 38.1 ± 23.6 vs. - 42.2 ± 23.0 °/ms), being significantly different between the groups at the 3-month time point (p < 0.05). In conclusion, whereas E/A ratio and E/Em ratio did not change significantly after 3 months of metabolic dysfunction, peak untwisting velocity was significantly decreased. Hence, peak untwisting velocity may serve as an important marker to detect early changes of LV diastolic dysfunction.

Evolution of subclinical myocardial dysfunction detected by two-dimensional and three-dimensional speckle tracking in asymptomatic type 1 diabetic patients: a long‑term follow-up study

Background

We sought to assess the long-term evolution of left ventricular (LV) function using two-dimensional (2D) and three-dimensional (3D) speckle tracking echocardiography (STE) for the detection of preclinical diabetic cardiomyopathy, in asymptomatic type 1 diabetic patients, over a 6-year follow-up.

Design and methods

Sixty-six asymptomatic type 1 diabetic patients with no cardiovascular risk factors were compared to 26 matched healthy controls. Conventional, 2D and 3D-STE were performed at baseline. A subgroup of 14 patients underwent a 6-year follow-up evaluation.

Results

At baseline, diabetic patients had similar LV ejection fraction (60 vs 61%; P = NS), but impaired longitudinal function, as assessed by 2D-global longitudinal strain (GLS) (−18.9 ± 2 vs −20.5 ± 2; P = 0.0002) and 3D-GLS (−17.5 ± 2 vs −19 ± 2; P = 0.003). At follow-up, diabetic patients had worsened longitudinal function compared to baseline (2D-GLS: −18.4 ± 1 vs −19.2 ± 1; P = 0.03). Global circumferential (GCS) and radial (GRS) strains were unchanged at baseline and during follow-up. Metabolic status did not correlate with GLS, whereas GCS and GRS showed a good correlation, suggestive of a compensatory increase of circumferential and radial functions in advanced stages of the disease – long-term diabetes (GCS: −26 ± 3 vs −23.3 ± 3; P = 0.008) and in the presence of microvascular complications (GRS: 38.8 ± 9 vs 34.3 ± 8; P = 0.04).

Conclusions

Subclinical myocardial dysfunction can be detected by 2D and 3D-STE in type 1 diabetic patients, independently of any other cardiovascular risk factors. Diabetic cardiomyopathy progression was suggested by a mild decrease in longitudinal function at the follow-up, but did not extend to a clinical expression of the disease, as no death or over heart failure was reported.

Central Obesity is the Key Component in the Association of Metabolic Syndrome With Left Ventricular Global Longitudinal Strain Impairment

INTRODUCTION AND OBJECTIVES

Subclinical systolic dysfunction is one of the proposed mechanisms for increased cardiovascular risk associated with metabolic syndrome (MS). This study investigated the association between MS and impaired left ventricular global longitudinal strain (GLS) and the role of each MS criteria in this association.

METHODS

We analyzed a random sample of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) after excluding participants with prevalent heart disease.

RESULTS

Among the 1055 participants fulfilling the inclusion criteria (53% women; 52±9 years), 444 (42%) had MS. Those with MS had worse GLS (-18.0%±2.5%) than those without (-19.0%±2.4%; P<.0001). In multiple linear regression models, MS was associated with worse GLS after adjustment for various risk factors (GLS difference=0.86%; P <.0001), even after inclusion of body mass index. Adjusted PR for impaired GLS as assessed by 3 cutoffs (1, 1.5, and 2 standard deviations) were higher among participants with than without MS: GLS -16.1% (PR, 1.76; 95%CI, 1.30-2.39); GLS -14.8% (PR, 2.35; 95%CI, 1.45-3.81); and GLS -13.5% (PR, 2.07; 95%CI, 0.97-4.41). After inclusion of body mass index in the models, these associations were attenuated, suggesting that they may, at least in part, be mediated by obesity. In quantile regression analyses, elevated waist circumference was the only MS component found to be independently associated with GLS across the whole range of values.

CONCLUSIONS

Metabolic syndrome is independently associated with impaired GLS. Among the MS criteria, central obesity best depicted the link between metabolic derangement and cardiac function.

Layer-specific deformation of the left ventricle in uncomplicated patients with type 2 diabetes and arterial hypertension

BACKGROUND

Detailed analysis of layer-specific mechanical changes in patients with type 2 diabetes mellitus (DM) might improve insight into left ventricular (LV) remodelling and diabetic cardiomyopathy.

AIM

We sought to investigate layer-specific LV deformation in patients with DM, with and without hypertension.

METHODS

This cross-sectional study included 146 subjects (44 controls; 48 patients with DM; 54 patients with DM and hypertension) who underwent complete examination by two-dimensional echocardiography (2DE), including multilayer strain analysis.

RESULTS

2DE LV longitudinal and circumferential strains deteriorated progressively and significantly from controls, through patients with DM, to patients with DM and hypertension. 2DE radial strain was lower in patients with DM and hypertension than in controls. 2DE longitudinal and circumferential mid-myocardial and epicardial layer strains decreased progressively from controls to patients with DM and hypertension, whereas endocardial layer strain was lower in patients with DM and patients with DM and hypertension than in controls. Variables of DM control (fasting glucose and glycated haemoglobin) were associated with 2DE LV longitudinal and circumferential layer-specific strains, independent of age, body mass index, blood pressure, LV diastolic function and hypertrophy in patients with DM.

CONCLUSION

DM and hypertension significantly affect LV deformation assessed by 2DE traditional strain and 2DE multilayer strain. Hypertension showed an additional negative effect on LV deformation in patients with DM. Fasting glucose and glycated haemoglobin were associated with LV mechanics evaluated by comprehensive 2DE strain analysis, independent of LV structure and diastolic function.

Impaired Left Atrial Conduit Function in Coronary Artery Disease Patients With Poorly Controlled Diabetes: Two-Dimensional Speckle-Tracking Echocardiographic Study

OBJECTIVES

The myocardium can be affected by diabetes mellitus. The effects of blood glucose control on some organs such as the kidney and eye have been previously reported. The aim of our study was to evaluate left atrial function via 2-dimensional (2D) speckle-tracking echocardiography in a group of coronary artery disease (CAD) patients with well-controlled diabetes (hemoglobin A1c [HbA1c] < 7%) and to compare it with that in a group of CAD patients with poorly controlled diabetes.

METHODS

This cross-sectional study included 110 CAD patients, comprising 44 euglycemic control patients, 33 patients with well-controlled diabetes (HbA1c < 7%), and 33 patients with poorly controlled diabetes. The study population thereafter underwent 2D speckle-tracking echocardiography for an evaluation of their left atrial function.

RESULTS

Our findings showed that the absolute values of early diastolic strain and early diastolic strain rate were lower in the CAD patients with poorly controlled diabetes than in the euglycemic control patients with CAD. Moreover, early diastolic strain in the CAD patients with poorly controlled diabetes was lower than that in the CAD patients with well-controlled diabetes. Multivariable analysis revealed that poorly controlled diabetes was an independent determinant of early diastolic strain and strain rate.

CONCLUSIONS

The conduit function of the left atrium was impaired in the CAD patients with poorly controlled diabetes compared with that in the euglycemic control patients with CAD and the CAD patients with well-controlled diabetes.

The relationship between heart rate variability and left ventricular layer-specific deformation in uncomplicated diabetic patients

The aim of this study was to investigate heart rate variability (HRV) and left ventricular (LV) remodeling in uncomplicated diabetic patients. Furthermore, we sought to investigate the association between HRV indices and LV structural, functional and mechanical parameters. This cross-sectional study included 50 uncomplicated patients with type 2 diabetes and 40 healthy controls without cardiovascular risk factors. All study subjects underwent 24-h Holter monitoring, laboratory analyses and complete two-dimensional echocardiography examination (2DE). LV structure and diastolic function were significantly deteriorated in the diabetic patients comparing with the controls. LV global longitudinal, circumferential and radial strains were significantly reduced in the diabetic group. LV endocardial, mid-miocardial and epicardial longitudinal and circumferential strains were significantly decreased, whereas LV twist was significantly increased, in the diabetic patients; 24-h, daytime and nighttime heart rates were higher in the diabetic patients. All parameters of time and frequency domain of HRV were reduced in the diabetic subjects. LV mass index, mitral E/e' ratio and 2DE LV endocardial and mid-miocardial longitudinal and circumferential strains correlated with HRV parameters. A multivariate regression analysis showed that E/e' ratio and 2DE LV layer-specific strains were associated with HRV parameters independently of age, BMI, systolic blood pressure and LV mass index. HRV and LV mechanics are significantly deteriorated in uncomplicated diabetic individuals. Parameters of LV remodeling are independently associated with HRV indices, which could indicate the importance of HRV determination in diabetics.

Evaluation of the Right Ventricular Function in Prediabetes: A 2-D Speckle Tracking Echocardiographic Study

Pre-diabetes is a common condition associated with cardiovascular changes. The aim of our study was to evaluate the right ventricular (RV) function as assessed by 2-D speckle tracking echocardiography in pre-diabetic patients. This study recruited 94 patients (33 normal patients, 31 pre-diabetic patients and 30 diabetic patients). The absolute amount of the global peak systolic strain, the systolic strain rate and the early diastolic strain rate of the RV free wall (RVFW) was higher in the control group than in the pre-diabetic and diabetic groups. These indices were not different between the pre-diabetic and diabetic groups. The global late diastolic strain rate of RVFW was the same between the three groups. Also, pre-diabetes and diabetes were the independent predictors of the RVFW global peak systolic strain, systolic strain rate and diastolic strain rate. Our study demonstrated that the RV systolic and diastolic functions were impaired in the pre-diabetic and diabetic patients without obstructive coronary artery disease. Also, pre-diabetes and diabetes were independent predictors of systolic and diastolic functions of the RV.

Left ventricular deformation associated with cardiomyocyte Ca(2+) transients delay in early stage of low-dose of STZ and high-fat diet induced type 2 diabetic rats

Background

In the early stage of diabetes, the cardiac ejection fraction is preserved, despite the existence of the subclinical cardiac dysfunction to some extent. However, the detailed phenotype of this dysfunction and the underlying mechanism remain unclear. To improve our understanding of this issue, we used low-dose STZ and high-fat diet to induce type 2 diabetic models in rats. The effects and the mechanism associated with the early stages of the disease were analyzed.

Methods

The type 2 diabetic mellitus (T2DM) in SD rats were induced through 30 mg/kg STZ and high-fat diet. Two-dimensional spackle-tracking echocardiography (STE) and the dobutamine test were performed to examine the cardiac function. Calcium transients of left ventricular myocytes were detected and the related intracellular signalling factors were analyzed by western blotting.

Results

After 6-weeks, T2DM rats in left ventricular (LV) diastole showed decreased global and segment strain(S) levels (P < 0.05), both in the radial and circumferential directions. Strain rate (Sr) abatement occurred in three segments in the radial and circumferential directions (P < 0.05), and the radial global Sr also decreased (P < 0.05). In the systolic LV, radial Sr was reduced, except the segment of the anterior septum, and the Sr of the lateral wall and post septum decreased in the circumferential direction (P < 0.05). Conventional M-mode echocardiography failed to detect significant alterations of cardiac performance between the two groups even after 12 weeks, and the decreased ejection fraction (EF%), fractional shortening (FS%) and end-systolic diameters (ESD) could be detected only under stress conditions induced by dobutamine (P < 0.05). In terms of calcium transients in cardiac myocytes, the T_peak in model rats at 6 weeks was not affected, while the T_decay1/2 was higher than that of the controls (P < 0.05), and both showed a dose-dependent delay after isoproterenol treatment (P < 0.05). Western blot analysis showed that in 6-week T2DM rats, myocardial p-PLB expression was elevated, whereas p-CaMKII, p-AMPK and Sirt1 were significantly down-regulated (P < 0.05).

Conclusion

A rat model of T2DM was established by low dose STZ and a high-fat diet. LV deformation was observed in the early stages of T2DM in association with the delay of Ca²⁺ transients in cardiomyocytes due to the decreased phosphorylation of CaMKII. Myocardial metabolism remodeling might contribute to the early LV function and calcium transportation abnormalities.

Comparison of Changes in Global Longitudinal Peak Systolic Strain After ST-Segment Elevation Myocardial Infarction in Patients With Versus Without Diabetes Mellitus

Global longitudinal strain (GLS) measured by 2-dimensional longitudinal speckle-tracking echocardiography may be a more sensitive measure of left ventricular (LV) mechanics than conventional LV ejection fraction (EF) to characterize adverse post-ST-segment elevation myocardial infarction (STEMI) remodeling. The aim of the present evaluation was to compare changes in LV GLS in patients with versus without diabetes after the first STEMI. Patients with first STEMI and diabetes (n = 143; age 64 ± 12 years; 68% men; 50% left anterior descending artery as culprit vessel) and 290 patients with first STEMI and without diabetes matched on age, gender, and infarct location were included. LV volumes and function and 2-dimensional LV GLS were measured after primary percutaneous coronary intervention (baseline) and at 6-month follow-up. At baseline, patients with and without diabetes had similar LVEF (46.8 ± 0.7% vs 48.0 ± 0.5%, p = 0.19) and infarct size (peak cardiac troponin T: 3.1 [1.2 to 6.5] vs 3.7 [1.3 to 7.3] μg/l, p = 0.10; peak creatine phosphokinase:1,120 [537 to 2,371] vs 1,291 [586 to 2,613] U/l, p = 0.17), whereas LV GLS was significantly more impaired in diabetic patients (-13.7 ± 0.3% vs -15.3 ± 0.2%, p <0.001). Although diabetic patients showed an improvement in LVEF over time similar to nondiabetic patients (52.0 ± 0.8% vs 53.1 ± 0.6%, p = 0.25), GLS remained more impaired at 6-month follow-up compared with nondiabetic patients (-15.8 ± 0.3% vs -17.3 ± 0.2%, p <0.001). After adjusting for clinical and echocardiographic characteristics, diabetes was independently associated with changes in GLS from baseline to 6-month follow-up (β 1.41, 95% confidence interval 0.85 to 1.96, p <0.001). In conclusion, after STEMI, diabetic patients show more impaired LV GLS at both baseline and follow-up compared with a matched group of patients without diabetes, despite having similar infarct size and LVEF at baseline and follow-up.

Subclinical LV dysfunction and 10-year outcomes in type 2 diabetes mellitus

OBJECTIVE

New imaging techniques have permitted the detection of subclinical LV dysfunction (LVD) in up to half of patients with type 2 diabetes mellitus (DM) with a normal EF. However, the connection between early LVD and prognosis is unclear. This study aimed to define the long-term outcome of LVD associated with type 2 DM.

METHODS

In this prospective cohort study, 230 asymptomatic patients with type 2 DM underwent measurement of global longitudinal 2D strain (GLS) for detection of LVD and were followed for up to 10 years. All subjects had normal EF (≥50%) and no evidence of coronary artery disease at recruitment. Outcome data were obtained through centralised state-wide death and hospital admission registries. The primary endpoint was all-cause mortality and hospitalisation.

RESULTS

On study entry, almost half (45%) of the cohort had evidence of LVD as detected by GLS. Over a median follow-up of 7.4±2.6 years (range 0.6-9.7 years), 68 patients (30%) met the primary endpoint (LVD: 37%; normal LV function: 24%). GLS was independently associated with the primary endpoint (HR=1.10; p=0.04), as was systolic blood pressure (HR=1.02; p<0.001) and levels of glycosylated haemoglobin (HR=1.28; p=0.011). Patients with LVD had significantly worse outcome than those without (χ(2)=4.73; p=0.030).

CONCLUSIONS

Subclinical LVD is common in asymptomatic patients with type 2 DM, is readily detectable by GLS imaging and is independently associated with adverse outcome.

TRIAL REGISTRATION NUMBER

Australian and New Zealand Clinical Trials Registry (ACTRN12612001178831).

Delayed longitudinal myocardial function recovery after dobutamine challenge as a novel presentation of myocardial dysfunction in type 2 diabetic patients without angiographic coronary artery disease

AIMS

Since myocardial dysfunction in diabetic patients without coronary artery disease (CAD) is subtle at rest, the assessment during dobutamine stress echocardiography (DSE) may be more sensitive for detection of myocardial involvement. We assessed systolic function of the left ventricle during all stages of DSE in 3 diabetic patients free of significant CAD using state-of-the-art speckle-tracking quantification.

METHODS AND RESULTS

We performed DSE in 250 patients with angina recording views during baseline (0), peak (1), and recovery phase (2). All patients had coronary anatomy verified with ≥ 50% stenosis in left main and ≥ 70% in other arteries considered as significant. In this analysis, we included 25 subjects with diabetes mellitus (DM) but without CAD (mean age 62 ± 8) and compared them with an age- and sex-matched group of 85 controls without DM and CAD (mean age 60 ± 9). Global peak systolic longitudinal strain (PSLS) of the left ventricle was obtained by automated function imaging (AFI) at rest, peak, and recovery phase of DSE. The global PSLS was similar in both groups at baseline (-17.3 ± 4.0% in diabetics vs. -18.7 ± 3.3% in controls, P = ns) and at peak stage of DSE (-16.4 ± 4.5% in diabetics vs. -17.9 ± 4.2% in controls, P = ns), whereas at recovery absolute value was lower in patients with DM (-15.3 ± 3.2% vs. -17.2 ± 3.3%, P = 0.01).

CONCLUSION

Peak systolic longitudinal strain measured by AFI during recovery of DSE was impaired in diabetic patients. It may reflect longer time needed for full restoration of myocardial systolic function in this group of subjects.

Diagnostic power of longitudinal strain at rest for the detection of obstructive coronary artery disease in patients with type 2 diabetes mellitus

Global longitudinal strain (GLS) measured by 2-D speckle-tracking echocardiography (2-D STE) at rest has been recognized as a sensitive parameter in the detection of significant coronary artery disease (CAD). However, the diagnostic power of 2-D STE in the detection of significant CAD in patients with diabetes mellitus is unknown. Two-dimensional STE features were studied in total of 143 consecutive patients who underwent echocardiography and coronary angiography. Left ventricular global and segmental peak systolic longitudinal strains (PSLSs) were quantified by speckle-tracking imaging. In the presence of obstructive CAD (defined as stenosis ≥75%), global PSLS was significantly lower in patients with diabetes mellitus than in patients without (16.65 ± 2.29% vs. 17.32 ± 2.27%, p < 0.05). Receiver operating characteristic analysis revealed that global PSLS could effectively detect obstructive CAD in patients without diabetes mellitus (cutoff value: -18.35%, sensitivity: 78.8%, specificity: 77.5%). However, global PSLS could detect obstructive CAD in diabetic patients at a lower cutoff value with inadequate sensitivity and specificity (cutoff value: -17.15%; sensitivity: 61.1%, specificity: 52.9%). In addition, the results for segmental PSLS were similar to those for global PSLS. In conclusion, global and segmental PSLSs at rest were significantly lower in patients with both obstructive CAD and diabetes mellitus than in patients with obstructive CAD only; thus, PSLSs at rest might not be a useful parameter in the detection of obstructive CAD in patients with diabetes mellitus.

Evaluation of cardiac function by two-dimensional speckle tracking echocardiography in ulcerative colitis patients

PURPOSE

Although ulcerative colitis (UC) shows obvious similarities with other autoimmune diseases, cardiac consequences have not adequately introduced. The aim of our study was to evaluate left ventricular (LV) function in UC patients by using novel echocardiographic parameters.

RESULTS

Forty-five UC patients (mean age 37, 18 female) and 90 age- and sex-matched healthy volunteers (mean age 40, 38 female) included in the study. The mean disease activity score according to partial Mayo score was 2.16 ± 2.13. Mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) measurements were significantly lower (-21.16 ± 2.71 vs. -23.36 ± 3.34; p < 0.001 and -1.33 ± 0.24 vs. -1.43 ± 0.24; p = 0.037, respectively), whereas global circumferential (-22.67 ± 3.66 vs. -23.37 ± 3.99; p = 0.140) and global radial strain (43.07 ± 8.58 vs. 44.12 ± 9.32; p = 0.545) measurements of the LV were similar in patients with UC compared with controls. The correlation coefficient (r) between GLS and partial Mayo score was -0.578 (p < 0.001).

CONCLUSION

Our study suggests that systolic cardiac deformation values are impaired in UC patients. Reduced GLS and GLSR might be an early indicator of cardiac involvement in this population.

The influence of type 2 diabetes on left atrial remodeling

The influence of type 2 diabetes mellitus on cardiac remodeling has been evaluated for decades; however, the majority of investigations were focused only on the left ventricle. The impact of diabetes on the left atrial (LA) function is less researched. LA enlargement has been shown as an independent predictor of cardiovascular morbidity and mortality in the general and diabetic population; however, LA dysfunction has been proven to be an independent predictor only in the general population. There are not much follow-up data about the influence of diabetes on LA function. New echocardiographic techniques, such as 2-dimensional speckle tracking imaging, provide more accurate, sensitive, and reliable information about LA function than traditional, volumetric methods. The aim of this review was to summarize the most recent reports about the influence of diabetes on LA function, as well as to discuss the possible mechanisms and potential clinical implications of the relationship between diabetes and LA remodeling.

Early myocardial deformation changes in hypercholesterolemic and obese children and adolescents: a 2D and 3D speckle tracking echocardiography study

Dyslipidemia and obesity are considered strong risk factors for premature atherosclerotic cardiovascular disease and increased morbidity and mortality and may have a negative impact on myocardial function.Our purpose was to assess the presence of early myocardial deformation abnormalities in dyslipidemic children free from other cardiovascular risk factors, using 2-dimensional speckle tracking echocardiography (2DSTE) and 3-dimensional speckle tracking echocardiography (3DSTE).We studied 80 consecutive nonselected patients (6-18 years of age) with hypercholesterolemia (low-density lipoprotein [LDL] cholesterol levels >95th percentile for age and sex). Forty of them had normal weight and 40 were obese (body mass index >95th percentile for age and sex). Forty healthy age-matched children were selected as controls. Left ventricular (LV) global longitudinal, circumferential, and radial strains were calculated by 2DSTE and 3DSTE. Global area strain (GAS) was calculated by 3DSTE as percentage of variation in surface area defined by the longitudinal and circumferential strain vectors. Right ventricular (RV) global and free-wall longitudinal strain and LV and RV diastolic strain rate parameters were obtained. Data analysis was performed offline.LV global longitudinal strain and GAS were lower in normal-weight and obese dyslipidemic children compared with normal controls and reduced in obese patients compared with normal-weight dyslipidemic children. LV early diastolic strain rate was lower compared with normals. RV global and free-wall longitudinal strain was significantly reduced in obese patients when compared with the control group. A significant inverse correlation was found between LV strain, LDL cholesterol levels, and body mass index.2DSTE and 3DSTE show LV longitudinal strain and GAS changes in dyslipidemic children and adolescents free from other cardiovascular risk factors or structural cardiac abnormalities. Obesity causes an additive adverse effect on LV strain parameters and RV strain impairment.

Echocardiographic follow-up of patients with systemic sclerosis by 2D speckle tracking echocardiography of the left ventricle

Background

Subclinical myocardial involvement is common in systemic sclerosis (SSc) and associated with poor prognosis. Early detection, particularly during follow-up, is important. Two-dimensional speckle tracking echocardiography (STE) has already been shown to detect early left ventricular systolic impairment in SSc patients with advanced disease. The aim of this study was to assess the ability of STE to diagnose changes in left ventricular function in patients with SSc with preserved LV ejection fraction (LVEF) and normal pulmonary pressure over time.

Methods

This single-center pilot study included nineteen SSc patients without pulmonary hypertension and preserved LVEF (55.2 ± 10.8 years, 13 women, mean modified Rodnan Skin Score of 8.2 ± 6.5, median disease duration 6 ± 4.5 years). We performed STE at baseline and after two years (mean 756.6 ± 8.8 days). Pulmonary hypertension was ruled out in all patients by right heart catheterization (average mean PAP 17.7 ± 3.5 mmHg).

Results

The LVEF remained unchanged (63.3 ± 4.2% vs. 63.2 ± 5.0%, P = ns), but the global longitudinal peak systolic strain of the left ventricle was significantly lower: baseline -22.0 ± 2.3% vs. follow-up -20.8 ± 2.1% (P = 0.04). The regional analysis showed a heterogeneous distribution of segmental systolic dysfunction that did not match any particular coronary artery distribution. In contrast, the LV diastolic function remained stable during follow-up.

Conclusion

STE might be a sensititive and valuable method to detect early LV systolic impairment in patients with SSc and preserved LVEF during two years. Prospective evaluations are needed for prognostic implications of these changes.