Author + information
- Received December 18, 2017
- Revision received March 22, 2018
- Accepted March 22, 2018
- Published online October 1, 2018.
- Ying Wang, MDa,
- Hong Yang, MBa,
- Quan Huynh, MB, PhDa,b,
- Mark Nolan, MBBSa,
- Kazuaki Negishi, MD, PhDa and
- Thomas H. Marwick, MBBS, PhD, MPHa,b,∗ ()
- aMenzies Institute for Medical Research, Hobart, Australia
- bBaker Heart and Diabetes Institute, Melbourne, Australia
- ↵∗Address for correspondence:
Prof. Thomas H. Marwick, Baker Heart and Diabetes Institute, 75 Commercial Road, Melbourne, VIC 3004, Australia.
Objectives This study sought to identify whether impaired global longitudinal strain (GLS), diastolic dysfunction (DD), or left atrial enlargement (LAE) should be added to stage B heart failure (SBHF) criteria in asymptomatic patients with type 2 diabetes mellitus.
Background SBHF is a precursor to clinical heart failure (HF), and its recognition justifies initiation of cardioprotective therapy. However, original definitions of SBHF were based on LV hypertrophy and impaired ejection fraction.
Methods Patients with asymptomatic type 2 diabetes mellitus ≥65 years of age (age 71 ± 4 years; 55% men) with preserved ejection fraction and no ischemic heart disease were recruited from a community-based population. All underwent a standard clinical evaluation, and a comprehensive echocardiogram, including assessment of left ventricular hypertrophy (LVH), LAE, DD (abnormal E/e′), and GLS (<16%). Over a median follow-up of 1.5 years (range 0.5 to 3), 20 patients were lost to follow-up, and 290 individuals were entered into the final analyses.
Results In this asymptomatic group, LV dysfunction was identified in 30 (10%) by DD, 68 (23%) by LVH, 102 (35%) by LAE, and 68 (23%) by impaired GLS. New-onset HF developed in 45 patients and 4 died, giving an event rate of 112/1,000 person-years. Survival free of the composite endpoint (HF and death) was about 1.5-fold higher in patients without a normal, compared with an abnormal echocardiogram. LVH, LAE, and GLS <16% were associated with increased risk of the composite endpoint, independent of ARIC risk score and glycosylated hemoglobin, but abnormal E/e′ was not. The addition of left atrial volume and GLS provided incremental value to the current standard of clinical risk (ARIC score) and LVH. In a competing-risks regression analysis, LVH (hazard ratio: 2.90; p < 0.001) and GLS <16% (hazard ratio: 2.26; p = 0.008), but not DD and LAE were associated with incident HF.
Conclusions Subclinical left ventricular systolic dysfunction is prevalent in asymptomatic elderly patients with type 2 diabetes mellitus, and impaired GLS is independent and incremental to LVH in the prediction of incident HF.
- global longitudinal strain
- stage B heart failure
- subclinical LV dysfunction
This study was partially supported by Tasmanian Community Fund and Diabetes Australia Research Trust. Neither of these agencies had any role in design, analysis, or interpretation of this study. The study was approved by the Tasmanian Human Research Ethics Committee. Dr. Marwick has received in kind support from GE Medical Systems for a trial of myocardial strain imaging for the assessment of cardiotoxicity from chemotherapy, unrelated to this study. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Paul Grayburn, MD, served as the Guest Editor for this paper.
- Received December 18, 2017.
- Revision received March 22, 2018.
- Accepted March 22, 2018.
- 2018 American College of Cardiology Foundation
This article requires a subscription or purchase to view the full text. If you are a subscriber or member, click Login or the Subscribe link (top menu above) to access this article.