Associations of (pre)diabetes with right ventricular and atrial structure and function: the Maastricht Study

A novel 3D imaging approach for quantification of GLUT4 levels across the intact myocardium

Cellular heterogeneity is a well-accepted feature of tissues, and both transcriptional and metabolic diversity have been revealed by numerous approaches, including optical imaging. However, the high magnification objective lenses needed for high-resolution imaging provides information from only small layers of tissue, which can result in poor cell statistics. There is therefore an unmet need for an imaging modality that can provide detailed molecular and cellular insight within intact tissue samples in 3D. Using GFP-tagged GLUT4 as proof of concept, we present here a novel optical mesoscopy approach that allows precise measurement of the spatial location of GLUT4 within specific anatomical structures across the myocardium in ultrathick sections (5 mm×5 mm×3 mm) of intact mouse heart. We reveal distinct GLUT4 distribution patterns across cardiac walls and highlight specific changes in GLUT4 expression levels in response to high fat diet-feeding, and we identify sex-dependent differences in expression patterns. This method is applicable to any target that can be labelled for light microscopy, and to other complex tissues when organ structure needs to be considered simultaneously with cellular detail.

The right ventricular dysfunction and ventricular interdependence in patients with T2DM and aortic regurgitation: an assessment using CMR feature tracking

BACKGROUND

Patients with concomitant type 2 diabetes mellitus (T2DM) and aortic regurgitation (AR) can present with right ventricular (RV) dysfunction. The current study aimed to evaluate the impact of AR on RV impairment and the importance of ventricular interdependence using cardiac magnetic resonance feature tracking (CMR‑FT) in patients with T2DM.

METHODS

This study included 229 patients with T2DM (AR-), 88 patients with T2DM (AR+), and 122 healthy controls. The biventricular global radial strain (GRS), global circumferential strain (GCS), and global longitudinal peak strain (GLS) were calculated with CMR‑FT and compared among the healthy control, T2DM (AR-), and T2DM (AR+) groups. The RV regional strains at the basal, mid, and apical cavities between the T2DM (AR+) group and subgroups with different AR degrees were compared. Backward stepwise multivariate linear regression analyses were performed to determine the effects of AR and left ventricular (LV) strains on RV strains.

RESULTS

The RV GLS, LV GRS, LV GCS, LV GLS, interventricular septal (IVS) GRS and IVS GCS were decreased gradually from the controls through the T2DM (AR-) group to the T2DM (AR+) group. The IVS GLS of the T2DM (AR-) and T2DM (AR+) groups was lower than that of the control group. AR was independently associated with LV GRS, LV GCS, LV GLS, RV GCS, and RV GLS. If AR and LV GLSs were included in the regression analyses, AR and LV GLS were independently associated with RV GLS.

CONCLUSION

AR can exacerbate RV dysfunction in patients with T2DM, which may be associated with the superimposed strain injury of the left ventricle and interventricular septum. The RV longitudinal and circumferential strains are important indicators of cardiac injury in T2DM and AR. The unfavorable LV-RV interdependence supports that while focusing on improving LV function, RV dysfunction should be monitored and treated in order to slow the progression of the disease and the onset of adverse outcomes.

Improvements of myocardial strain and work in diabetes patients with normal ejection fraction after empagliflozin treatment

AIMS/INTRODUCTION

To assess the effect of empagliflozin treatment on left ventricular (LV), right ventricular (RV) and left atrial (LA) functions in diabetes patients with normal ejection fraction.

MATERIALS AND METHODS

The study included a total of 128 diabetes patients with multiple cardiovascular risk factors who were subjected to a 6-month follow up from the initiation of empagliflozin treatment. Before and after treatment with empagliflozin, LV, RV and LA strain, and noninvasive myocardial work parameters were evaluated by speckle tracking echocardiography.

RESULTS

In 128 diabetes patients (mean age 56 ± 8 years, 85 men) with multiple cardiovascular risk factors, myocardial strain and work parameters were impaired, despite the absence of significant clinical symptoms of heart failure. After 6-month treatment with empagliflozin, the absolute value of LV strain in all directions increased, represented by LV global longitudinal strain (-18.0 ± 1.7% to -19.2 ± 1.7% [mean ± SD]). The same trend in LV global work efficiency (93 [91-94] % to 94 [93-95] % [median (IQR)]), RV free-wall longitudinal strain (-24.0 ± 2.7% to -25.0 ± 2.8%), LA reservoir (31 ± 5% to 34 ± 5%) and conduit strain (-14 ± 4% to -16 ± 4%) was also observed. LV mass index (106.9 ± 16.8-103.6 ± 16.4 g/m2) and LV global wasted work (143 [111-185] mmHg% to 108 [88-141] mmHg%) decreased after treatment (P < 0.05 for all). LV volume and LA volume index remained unchanged after treatment. In the multivariable analysis, the change in LA reservoir strain (β = 0.050, P = 0.035) and baseline global longitudinal strain (β = -0.488, P < 0.001) were independent predictors of improvement in LV global longitudinal strain.

CONCLUSIONS

This study suggests that 6-month treatment with empagliflozin improved LV, RV and LA functions in diabetes patients with normal ejection fraction.

[Pulmonary heart: A review]

The review on the problem of the pulmonary heart pursues two goals: firstly, to restore historical justice and to show the priority studies of doctor Dmitry D. Pletnev on such problems as diagnosis of right ventricular myocardial infarction, clinical characteristics of congestive heart failure of the right ventricle; secondly, to outline the modern concept of the pulmonary heart. The review provides an analysis of the pathogenetic mechanisms of the development of heart failure in the pulmonary heart. Much attention is paid to echo cardiography data and biological markers are emphasized in assessing the function of the right atrium, right ventricle, tricuspid valve regurgitation, pulmonary artery pressure. Prognostically unfavorable signs of the course of the pulmonary heart have been identified, which include a high degree of tricuspid valve regurgitation, the amplitude of movement of the fibrous valve ring (TAPSE) and atrial fibrillation developing with dilation of the right atrium.

Effects of diabetes mellitus and glycemic traits on cardiovascular morpho-functional phenotypes

BACKGROUND

The effects of diabetes on the cardiac and aortic structure and function remain unclear. Detecting and intervening these variations early is crucial for the prevention and management of complications. Cardiovascular magnetic resonance imaging-derived traits are established endophenotypes and serve as precise, early-detection, noninvasive clinical risk biomarkers. We conducted a Mendelian randomization (MR) study to examine the association between two types of diabetes, four glycemic traits, and preclinical endophenotypes of cardiac and aortic structure and function.

METHODS

Independent genetic variants significantly associated with type 1 diabetes, type 2 diabetes, fasting insulin (FIns), fasting glucose (FGlu), 2 h-glucose post-challenge (2hGlu), and glycated hemoglobin (HbA1c) were selected as instrumental variables. The 96 cardiovascular magnetic resonance imaging traits came from six independent genome-wide association studies. These traits serve as preclinical endophenotypes and offer an early indication of the structure and function of the four cardiac chambers and two aortic sections. The primary analysis was performed using MR with the inverse-variance weighted method. Confirmation was achieved through Steiger filtering and testing to determine the causal direction. Sensitivity analyses were conducted using the weighted median, MR-Egger, and MR-PRESSO methods. Additionally, multivariable MR was used to adjust for potential effects associated with body mass index.

RESULTS

Genetic susceptibility to type 1 diabetes was associated with increased ascending aortic distensibility. Conversely, type 2 diabetes showed a correlation with a reduced diameter and areas of the ascending aorta, as well as decreased distensibility of the descending aorta. Genetically predicted higher levels of FGlu and HbA1c were correlated with a decrease in diameter and areas of the ascending aorta. Furthermore, higher 2hGlu levels predominantly showed association with a reduced diameter of both the ascending and descending aorta. Higher FIns levels corresponded to increased regional myocardial-wall thicknesses at end-diastole, global myocardial-wall thickness at end-diastole, and regional peak circumferential strain of the left ventricle.

CONCLUSIONS

This study provides evidence that diabetes and glycemic traits have a causal relationship with cardiac and aortic structural and functional remodeling, highlighting the importance of intensive glucose-lowering for primary prevention of cardiovascular diseases.

Subclinical right ventricular dysfunction in patients with asymptomatic type 2 diabetes mellitus: A cross-sectional study

BACKGROUND

Diabetic cardiomyopathy, which involves both the right and left ventricles, progresses from a preclinical stage to overt heart failure. Detection of this entity at a preclinical stage could be crucial in intervening to halt its progression to overt heart failure. There is a paucity of literature on subclinical RV dysfunction in diabetic patients, and it is even rarer in the Indian literature. Our study intended to study this clinical entity through an echocardiographic assessment of asymptomatic patients.

OBJECTIVES

This was a cross-sectional observational analytic study, comparing subclinical RV dysfunction in diabetic and non-diabetic subjects by using echocardiography as a primary objective, while the secondary objective of the study was to find out the correlation between RV dysfunction and the duration of diabetes mellitus and HbA1C levels.

METHODS

Conventional echocardiography with tissue Doppler imaging (TDI) was used to measure nine different echocardiographic parameters in the diabetic and non-diabetic groups. All probable causes of RV dysfunction were excluded before enrolling the patients in the study. Unpaired t-test was used to compare the parameters between the two groups, and multivariate regression analysis was done taking into consideration age, duration of diabetes, and HbA1C levels as the independent variables, and echocardiographic parameters as the dependent variables.

RESULTS

Out of the nine different echocardiographic parameters, Tricuspid annular plane systolic excursion (TAPSE), RV end diastolic diameter (RVEDD), Tricuspid peak late diastolic velocity (A), E/A ratio, RV basal segment peak myocardial systolic velocity (Sm), RV basal segment peak early diastolic velocity (Em), RV basal segment peak late diastolic velocity (Am), and E/Em ratio showed statistically significant differences between the two groups. These results show the presence of subclinical RV dysfunction in diabetic patients. TAPSE and E/A ratio showed a significant correlation with the duration of diabetes, while Em showed a significant correlation with HbA1C.

CONCLUSION

Diabetes mellitus is associated with subclinical systolic as well as diastolic RV dysfunction. In addition to helping identify people at high risk, the early recognition of RV dysfunction gives us a window of opportunity to take action and slow down the disease's course. This study emphasizes that the early identification of RV diastolic as well as systolic dysfunction in asymptomatic Type 2 diabetic patients can be a helpful tool in halting the progression of disease from subclinical to frank clinical cases, thereby preventing the morbidity and mortality associated with heart failure. Hence, it adds value to the pre-existing literature.

Early impairment of right ventricular systolic function in patients with prediabetes and type 2 diabetes mellitus: An analysis of two-dimensional speckle tracking echocardiography

BACKGROUND

Type 2 diabetes mellitus is a metabolic disease that affects multiple target organs. Current data on right ventricular damage in type 2 diabetes, especially in prediabetes, are limited. Due to the anatomical characteristics of the right ventricle, the assessment of the right ventricle by conventional echocardiography is difficult, whereas the ultrasound two-dimensional speckle tracking echocardiography can provide information on myocardial systolic function by tracking the motion information of myocardial speckles, which can sensitively reflect myocardial mechanical changes.

AIMS

To assess the effect of prediabetes and diabetes with preserved left ventricular ejection fraction on right ventricular myocardial systolic function and to identify independent risk factors affecting right ventricular systolic function.

METHODS

A total of 49 normoglycaemic (NG) healthy individuals, 43 prediabetics (PDM), and 52 type 2 diabetics (T2DM) were recruited. All study subjects underwent conventional echocardiography and two-dimensional speckle tracking echocardiography (2D-STE).

RESULTS

The right ventricular global longitudinal strain (RVGLS) (20.80 ± 1.96% vs. 18.99 ± 3.20% vs. 16.85 ± 4.01%), left ventricular global longitudinal strain (LVGLS), and interventricular septal longitudinal strain (IVS-LS) (17.28 ± 2. 35% vs. 16.14 ± 3.22% vs. 15.53 ± 3.33%) gradually decreased from the controls, through patients with prediabetes, to those with diabetes (p < .001). Right ventricular free wall strain (RVFW-LS) was higher in the control group (25.63 ± 4.58% vs. 22.83 ± 4.83% vs. 20.79 ± 4.92%) than in the other two groups with a statistically significant difference (p < .001), while RVFW-LS was not statistically different between the prediabetic and diabetic groups. Multivariate regression analysis showed that HbA1c (β = -.626, p < .001), IVS-LS (β = .417, p < .001), and left ventricular end-diastolic diameter (LVEDd) (β = .191, p = .011) were independently correlated with RVGLS.

CONCLUSIONS

Two-dimensional speckle tracking echocardiography can sensitively detect subtle changes in the early impairment of right ventricular systolic function in patients with abnormal glucose metabolism. Type 2 diabetes is the common mechanism causing impaired myocardial mechanics in the right and left ventricles. The reduced global systolic longitudinal strain of the right ventricle was associated with reduced global septal longitudinal strain and left ventricular remodeling. HbA1c is an independent predictor of the global longitudinal strain of the right ventricle, and controlling blood glucose levels may be expected to improve the extent of myocardial damage.

The right ventricular dysfunction and ventricular interdependence in patients with DM: assessment using cardiac MR feature tracking

BACKGROUND

To investigate the difference of right ventricular (RV) structural and functional alteration in patients with diabetes mellitus (DM) with preserved left ventricular ejection fraction (LVEF), and the ventricular interdependence in these patients, using cardiac MR (CMR) feature tracking.

METHODS

From December 2016 to February 2022, 148 clinically diagnosed patients with DM who underwent cardiac MR (CMR) in our hospital were consecutively recruited. Fifty-four healthy individuals were included as normal controls. Biventricular strains, including left/right ventricular global longitudinal strain (LV-/RVGLS), left/right ventricular global circumferential strain (LV-/RVGCS), left/right ventricular global radial strain (LV-/RVGRS) were evaluated, and compared between patients with DM and healthy controls. Multiple linear regression and mediation analyses were used to evaluate DM's direct and indirect effects on RV strains.

RESULTS

No differences were found in age (56.98 ± 10.98 vs. 57.37 ± 8.41, p = 0.985), sex (53.4% vs. 48.1%, p = 0.715), and body surface area (BSA) (1.70 ± 0.21 vs. 1.69 ± 0.17, p = 0.472) between DM and normal controls. Patients with DM had decreased RVGLS (- 21.86 ± 4.14 vs. - 24.49 ± 4.47, p = 0.001), RVGCS (- 13.16 ± 3.86 vs. - 14.92 ± 3.08, p = 0.011), and no decrease was found in RVGRS (22.62 ± 8.11 vs. 23.15 ± 9.05, p = 0.743) in patients with DM compared with normal controls. The difference in RVGLS between normal controls and patients with DM was totally mediated by LVGLS (indirect effecting: 0.655, bootstrapped 95%CI 0.138-0.265). The difference in RVGCS between normal controls and DM was partly mediated by the LVGLS (indirect effecting: 0.336, bootstrapped 95%CI 0.002-0.820) and LVGCS (indirect effecting: 0.368, bootstrapped 95%CI 0.028-0.855).

CONCLUSIONS

In the patients with DM and preserved LVEF, the difference in RVGLS between DM and normal controls was totally mediated by LVGLS. Although there were partly mediating effects of LVGLS and LVGCS, the decrease in RVGCS might be directly affected by the DM.

Speckle tracking echocardiography in early disease stages: a therapy modifier?

Echocardiography has been included as a first-line tool in several international guidelines for the management of patients with various cardiac diseases. Beyond diagnosis, echocardiographic examination helps in characterizing the severity of the condition since the very first stages. In particular, the application of second-level techniques, speckle tracking echocardiography in particular, can also reveal a subclinical dysfunction, while the standard parameters are in the normality range. The present review describes the potentialities of advanced echocardiography in different settings, including arterial hypertension, atrial fibrillation, diastolic dysfunction, and oncological patients, thus opening up potential starting points for its application as a clinical routine changer.

Heart Failure Association-International Cardio-Oncology Society Risk Score Validation in HER2-Positive Breast Cancer

BACKGROUND

This paper looks to validate the risk score from the Heart Failure Association of the European Society of Cardiology and the International Cardio-Oncology Society (HFA-ICOS) for predicting potential cardiotoxicity from anticancer therapy for patients positive for human epidermal growth factor receptor 2.

METHODS

A total of 507 patients with at least five years since index diagnosis of breast cancer were retrospectively divided according to the HFA-ICOS risk proforma. According to level of risk, these groups were assessed for rates of cardiotoxicity via mixed-effect Bayesian logistic regression model.

RESULTS

A follow-up of five years observed cardiotoxicity of 3.3% (n = 3) in the low-risk, 3.3% (n = 10) in the medium-risk, 4.4% (n = 6) in the high-risk, and 38% (n = 6) in the very-high-risk groups respectively. For cardiac events related to treatment, the risk was significantly higher for the very-high-risk category of HFA-ICOS compared to other categories (Beta = 3.1, 95% CrI: 1.5, 4.8). For overall cardiotoxicity related to treatment, the area under the curve was 0.643 (CI 95%: 0.51, 0.76), with 26.1% (95% CI: 8%, 44%) sensitivity and 97.9% (95% CI: 96%, 99%) specificity.

CONCLUSIONS

The HFA-ICOS risk score has moderate power in predicting cancer therapy-related cardiotoxicity in HER2-positive breast cancer patients.

Impact of glycemic control on biventricular function in patients with type 2 diabetes mellitus: a cardiac magnetic resonance tissue tracking study

BACKGROUND

Poor glycemic control is associated with left ventricular (LV) dysfunction in patients with type 2 diabetes mellitus (T2DM). Nonetheless, the association between glycemic control and right ventricular (RV) function in T2DM has not been studied. This study aimed to evaluate the correlation between glycemic control and biventricular function and assess whether one ventricular function was mediated by the other ventricular changes using cardiac magnetic resonance.

MATERIALS AND METHODS

A total of 91 T2DM patients with normal ejection fraction were enrolled and divided into two groups according to glycated hemoglobin (HbA1c) with a cut off 7%. Twenty controls were included. Biventricular ventricular strain parameters, including global peak systolic radial strain, global peak systolic circumferential strain (GCS), global peak systolic longitudinal strain (GLS), peak diastolic radial strain rate (RSR), peak diastolic circumferential strain rate (CSR) and peak diastolic longitudinal strain rate (LSR) were measured.

RESULTS

Compared with controls, patients with both HbA1c < 7% and HbA1c ≥ 7% showed significantly lower LVGCS, LVGLS, LVCSR, LVLSR, RVGLS, RVRSR, RVCSR and RVLSR. Patients with HbA1c ≥ 7% elicited significantly higher RVGCS than controls and lower LVGLS, LVCSR, LVLSR, RVGLS and RVLSR. Multivariable linear regression demonstrated that HbA1c was independently associated with LVGLS, LVLSR, RVGLS and RVLSR after adjustment for traditional risk factors. LV (RV) was not statistically mediated by the other ventricular alterations.

CONCLUSION

In T2DM patients, glycemic control was independently associated with impaired LV and RV systolic and diastolic function and these associations were not mediated by the other ventricular changes.

Impact of T2DM on right ventricular systolic dysfunction and interventricular interactions in patients with essential hypertension: evaluation using CMR tissue tracking

Background

Previous studies reported that there was right ventricular (RV) systolic dysfunction in patients with hypertension. The aim of this study was to evaluate the impact of type 2 diabetes mellitus (T2DM) on RV systolic dysfunction and interventricular interactions using cardiac magnetic resonance feature tracking (CMR-FT) in patients with essential hypertension.

Methods and methods

Eighty-five hypertensive patients without T2DM [HTN(T2DM −)], 58 patients with T2DM [HTN(T2DM +)] and 49 normal controls were included in this study. The biventricular global radial, circumferential and longitudinal peak strains (GRS, GCS, GLS, respectively) and RV regional strains at the basal-, mid- and apical-cavity, were calculated with CMR-FT and compared among controls and different patient groups. Backward stepwise multivariable linear regression analyses were used to determine the effects of T2DM and left ventricular (LV) strains on RV strains.

Results

The biventricular GLS and RV apical longitudinal strain deteriorated significantly from controls, through HTN(T2DM-), to HTN(T2DM +) groups. RV middle longitudinal strain in patient groups were significantly reduced, and LV GRS and GCS and RV basal longitudinal strain were decreased in HTN(T2DM +) but preserved in HTN(T2DM-) group. Multivariable regression analyses adjusted for covariates demonstrated that T2DM was independently associated with LV strains (LV GRS: β = − 4.278, p = 0.004, model R2 = 0.285; GCS: β = 1.498, p = 0.006, model R2 = 0.363; GLS: β = 1.133, p = 0.007, model R2 = 0.372) and RV GLS (β = 1.454, p = 0.003, model R2 = 0.142) in hypertension. When T2DM and LV GLS were included in the multiple regression analysis, both T2DM and LV GLS (β = 0.977 and 0.362, p = 0.039 and < 0.001, model R2 = 0.224) were independently associated with RV GLS.

Conclusions

T2DM exacerbates RV systolic dysfunction in patients with hypertension, which may be associated with superimposed LV dysfunction by coexisting T2DM and suggests adverse interventricular interactions.

Relationship Between Epicardial Adipose Tissue and Biventricular Longitudinal Strain and Strain Rate in Patients with Type 2 Diabetes Mellitus

BACKGROUND

Epicardial adipose tissue (EAT) has been reported to be increased in patients with type 2 diabetes mellitus (T2DM). EAT thickness may impact left ventricular (LV) diastolic function. However, the association between EAT and right ventricular (RV) function in T2DM is unclear. We hypothesized an association between EAT volume and biventricular longitudinal strain and strain rate in patients with T2DM.

MATERIALS AND METHODS

A total of 20 controls and 69 T2DM patients with preserved LV ejection fraction (EF) who underwent cardiac magnetic resonance (CMR) were included. Biventricular function was evaluated by CMR Tissue-Tracking derived strain analysis, including LV global peak systolic longitudinal strain (LVGLS), peak diastolic longitudinal strain rate (LVLSR), RVGLS and RVLSR.

RESULTS

Compared to controls, patients with T2DM had significantly higher EAT volumes with lower LVGLS, LVLSR, RVGLS and RVLSR (all p<0.05). EAT volume was significantly correlated with LVGLS, LVLSR, RVGLS and RVLSR in T2DM patients (r=-0.45, -0.39, -0.59, -0.50, all p<0.001). Multivariate linear regression analysis revealed that EAT volume was significantly associated with LVGLS (β=0.38, p=0.001), LVLSR (β=-0.35, p=0.003), RVGLS (β=0.64, p<0.001) and RVLSR (β=-0.43, p<0.001) independently of traditional risk factors in patients with T2DM.

CONCLUSION

Patients with T2DM had higher EAT levels and lower biventricular function than controls. EAT volume was independently associated with biventricular longitudinal strain and strain rate in T2DM patients.

Benefits of Taking Sodium-Glucose Cotransporter 2 Inhibitors in Patients With Type 2 Diabetes Mellitus and Cardiovascular Disease: A Systematic Review

Type 2 diabetes mellitus (T2DM) is a significant cause of cardiovascular deaths worldwide. There are many oral antihyperglycemic drugs available to treat diabetic patients. Among them, sodium-glucose cotransporter 2 (SGLT2) inhibitors provide effective treatment in all stages of T2DM regardless of blood glucose levels and benefit the cardiovascular system. SGLT2 inhibitors have an additional diuretic effect that reduces blood pressure and hospitalizations and improves heart failure outcomes. This study will assess the efficacy of SGLT2 inhibitors in cardiovascular outcomes in patients with T2DM and cardiovascular disease. Our systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and involved a literature search utilizing PubMed and Google Scholar databases. In addition, we thoroughly searched for studies conducted in the last 10 years that corresponded with our outlined inclusion and exclusion criteria. Our search yielded 779 articles. The articles were then quality-checked before inclusion. We ultimately selected six randomized controlled trials and two meta-analyses of research articles after applying the inclusion and exclusion criteria. Our research study included 91,796 T2DM and cardiovascular disease patients. We examined cardiovascular outcomes among these T2DM patients, such as major adverse cardiac events (MACE), blood pressure, heart failure, and hospitalizations. Our study showed that SGLT2 inhibitors significantly reduce weight and blood pressure due to their natriuretic effects. In addition, they also improve heart failure symptoms and reduce hospitalizations.

Effects of Lipid Overload on Heart in Metabolic Diseases

Metabolic diseases are often associated with lipid and glucose metabolism abnormalities, which increase the risk of cardiovascular disease. Diabetic cardiomyopathy (DCM) is an important development of metabolic diseases and a major cause of death. Lipids are the main fuel for energy metabolism in the heart. The increase of circulating lipids affects the uptake and utilization of fatty acids and glucose in the heart, and also affects mitochondrial function. In this paper, the mechanism of lipid overload in metabolic diseases leading to cardiac energy metabolism disorder is discussed.

Association of left ventricular longitudinal myocardial function with subclinical right ventricular dysfunction in type 2 diabetes mellitus

Background

Left ventricular (LV) involvement in diabetic cardiomyopathy has been reported; however, only limited data exist on right ventricular (RV) involvement. Therefore, our purpose was to investigate RV systolic dysfunction and its association with LV longitudinal myocardial dysfunction in patients with type 2 diabetes mellitus (T2DM) and preserved LV ejection fraction (LVEF).

Methods

We studied 177 T2DM patients with preserved LVEF and 79 age-, sex-, and LVEF-matched healthy volunteers. LV longitudinal myocardial function was assessed as global longitudinal strain (GLS), and RV systolic function was assessed as RV free-wall strain, and predefined cutoff values for subclinical dysfunction were set at GLS < 18% and RV free-wall strain < 20%, respectively.

Results

RV free-wall strain in T2DM patients was significantly lower than that in normal controls (19.3% ± 4.8% vs. 24.4% ± 5.1%; P < 0.0001). RV free-wall strain in T2DM patients and LV longitudinal dysfunction was similar compared to that in T2DM patients without (19.0 ± 4.5% vs. 19.6 ± 5.0%, P = 0.40). Furthermore, multivariate logistic regression analyses showed that GLS was independently associated with RV systolic dysfunction as well as mitral inflow E and mitral e′ annular velocities ratio (odds ratio, 1.16; 95% confidence interval: 1.03–1.31; P < 0.05). Sequential logistic models evaluating the association of RV systolic dysfunction in T2DM patients showed an improvement in clinical variables (χ² = 6.2) with the addition of conventional echocardiographic parameters (χ² = 13.4, P < 0.001) and a further improvement with the addition of GLS (χ² = 20.8, P < 0.001).

Conclusion

RV subclinical systolic dysfunction was observed in T2DM patients with preserved LVEF and was associated with LV longitudinal myocardial dysfunction. Our findings may provide additional findings for the management of T2DM patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-021-01404-5.

Detection of early ultrasonographic markers of cardiovascular dysfunction in prediabetes patients: Cardiovascular markers in prediabetes

BACKGROUND

Prediabetes individuals may present incipient signals of cardiovascular injury and evaluate with unfavorable outcome. The aim of this study was to identify early ultrasonographic markers of cardiac dysfunction and arterial stiffness among glucose intolerant patients compared to healthy individuals.

METHODS

Cross-sectional study with the composition of two groups: Prediabetes (PD) who met the criteria for pre-diabetes and Normoglycemic (NG): presented no criteria of pre-diabetes and diabetes mellitus in all applied tests. Clinical evaluation, assessment of cardiac function by transthoracic echocardiogram, carotid intima-media thickness by carotid ultrasonographic and evaluation of arterial stiffness by SphygmoCor®ฏ device were performed.

RESULTS

Eighty adults were included in this study: PD (n=43) and NG (n=37). PD patients were more dyslipidemic and presented early alterations in echocardiographic variables, like: peak mitral velocity E (E (cm/s): NG 84±13 vs PD 77±11, p = 0.03), E/A Tricuspid inflow (NG: 1.5±0.4 vs PD 1.3±0.3, p=0.03), Tricuspid tissue Doppler E' (E'tric (cm/s): NG 15.2±4.4 vs PD 13.4±3.2, p=0.04) and increased arterial stiffness (Pulse Wave Velocity: PWV (m/s): NG 7.2±1.5 vs PD 7.9±1.7, p = 0.03). In the regression analysis, having an impaired oral glucose test was shown to be independently associated with reduced E Mitral, even after adjusting for a set of confounding factors.

CONCLUSION

PD patients showed early signals of an impaired cardiac function and an increased pulse wave velocity when compared with healthy individuals. These results point to treatment optimization strategies, especially when considering preventive measures for cardiovascular outcomes, like diabetic cardiomyopathy.

Impact of empagliflozin on right ventricular parameters and function among patients with type 2 diabetes

Background

Sodium-glucose cotransporter 2 (SGLT2) inhibition reduces cardiovascular events in type 2 diabetes (T2DM) and is associated with a reduction in left ventricular (LV) mass index. However, the impact on right ventricular (RV) remodeling is unknown. Accordingly, the objective of this study was to assess the impact of SGLT2 inhibition on RV parameters and function in T2DM and coronary artery disease (CAD).

Methods

In EMPA-HEART CardioLink-6, 97 patients with T2DM and CAD were randomly assigned to empagliflozin 10 mg (n = 49) once daily or placebo (n = 48). Cardiac magnetic resonance imaging was performed at baseline and after 6 months. RV mass index (RVMi), RV end-diastolic and end-systolic volume index (RVEDVi, RVESVi) and RV ejection fraction (RVEF) were assessed in blinded fashion.

Results

At baseline, mean RVMi (± SD) (11.8 ± 2.4 g/m²), RVEF (53.5 ± 4.8%), RVEDVi (64.3 ± 13.2 mL/m²) and RVESVi (29.9 ± 6.9 mL/m²) were within normal limits and were similar between the empagliflozin and placebo groups. Over 6 months, there were no significant differences in RVMi (− 0.11 g/m², [95% CI − 0.81 to 0.60], p = 0.76), RVEF (0.54%, [95% CI − 1.4 to 2.4], p = 0.58), RVEDVi (− 1.2 mL/m², [95% CI − 4.1 to 1.7], p = 0.41) and RVESVi (− 0.81 mL/m², [95% CI − 2.5 to 0.90], p = 0.35) in the empaglifozin group as compared with the placebo group. In both groups, there was no significant correlation between RVMi and LVMi changes from baseline to 6 months.

Conclusions

In this post-hoc analysis, SGLT2 inhibition with empagliflozin had no impact on RVMi and RV volumes in patients with T2DM and CAD. The potentially differential effect of empagliflozin on the LV and RV warrants further investigation.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov/ct2/show/NCT02998970?cond=NCT02998970&draw=2&rank=1. Unique identifier: NCT02998970.

Diabetes Mellitus and Heart Failure

Diabetes mellitus (DM) is a major risk factor for new-onset heart failure (HF) and vice versa. The pathogenesis of new-onset HF in DM is complex and has been largely attributed to the toxic cardiovascular effects of hyperglycemia and relevant metabolic abnormalities (diabetic cardiomyopathy) as well as the frequently coexisting morbidities such as hypertension (HTN), coronary artery disease (CAD), and diabetic nephropathy. In patients with type 1 DM (T1DM), HF develops in the setting of a dysregulated immune response, whereas in most patients with type 2 DM (T2DM), against a background of overweight/obesity. HF prevention in DM is feasible with rigorous treatment of cardiovascular risk factors and selective antidiabetic agents. Conversely, development of new-onset T2DM in HF (cardiogenic DM) is common and has been attributed to an increase in the resistance to insulin, especially in the skeletal muscle, liver, and adipose tissue as well as in diminished insulin secretory response to hyperglycemia by pancreatic β-cells. Cardiogenic DM further deteriorates cardiac dysfunction and adversely affects outcome in HF. Novel lifesaving medications employed in HF management such as sacubitril/valsartan and sodium glucose cotransporter 2 inhibitors (SGLT-2i) have a favorable metabolic profile and lower the incidence of cardiogenic diabetes. Whether mitigation of cardiogenic DM should be a treatment target in HF deserves further investigation.

Prevention of Diabetes and Cardiovascular Disease in Obesity

Obesity is one of the major risk factors for the development of both impaired glucose tolerance (IGT, or prediabetes) and type 2 diabetes (T2D), and its prevalence worldwide drives toward an increased rate of cardiovascular morbidity and mortality. Given the estimations of the World Health Organization (WHO) and the recommendation of the Diabetes Prevention Program (DPP), where IGT and diabetes are considered as risk factors for the development of cardiovascular complications and obesity, the development of diabetes should be treated because of its potential reversibility. In this view, several interventions such as diet, lifestyle changes, and pharmacological treatment are effective, including bariatric metabolic surgery (BMS), which is the most incisive way to efficiently lower body weight. In this review, we sought to summarize some of the major aspects linked to diabetes prevention in overweight/obesity, focusing on the use of surgery; we also attempted to elucidate molecular pathways involved in a variety of obesity-induced processes able to favor the progression of chronic diseases, such as diabetes and its complications.