Left ventricular function in diabetes mellitus. II: Relation between clinical features and left ventricular function.

We have shown a close relation between clinical microvascular complications and abnormalities of left ventricular function in 185 established diabetics without clinical heart disease. In 50 insulin-dependent diabetics who presented at under 20 years of age there was a correlation between the duration of diabetes and the isovolumic relaxation time, minimal dimension to mitral valve opening, and ratio of pre-ejection period to left ventricular ejection time. Diabetics with mild microvascular complications were similar to diabetics with no complications except for minor prolongation of the diastolic time intervals. Those with severe complications were significantly different from diabetes with milder complications and normal controls in all variables of left ventricular function. A close relation between left ventricular function and the microvascular complications index (code 0 when no complications to code 7 when all present and severe) was found for the following variables: isovolumic relaxation time, the interval from minimal dimension to mitral valve opening, ratio of pre-ejection period to left ventricular ejection time, and pre-ejection period index. It is concluded that in diabetes abnormalities of left ventricular function are related to duration of disease and complications; and that a diabetic specific heart muscle disorder occurs frequently in patients with severe microvascular complications.     

Left ventricular diastolic abnormalities in diabetes mellitus I in relation to cardiovascular autonomic neuropathy and retinopathy

In this study the authors evaluated left ventricular performance in two groups of type I diabetes, with or without autonomic neuropathy, using the pulsed Doppler echocardiographic method. They also evaluated the eventual presence of retinopathy in these groups. A significant left ventricular performance alteration was observed only in the first group (with autonomic neuropathy) in particular concerning the diastolic phase. In this group they found a significant correlation with the presence of retinopathy (p<0.01), in contrast to the second group, which had a lower incidence of retinopathy. It is possible to presume that diabetic patients with autonomic neuropathy had, as compared with a similar group without this feature, more nerve damage and also greater vascular damage, which can be expressed by the more significant presence of retinopathy and alteration of the left ventricular diastolic phase.     

Left ventricular function and dimensions in newly diagnosed non-insulin-dependent diabetes mellitus.

Left ventricular (LV) function and dimensions were assessed with Doppler and M-mode echocardiography in 26 men and 17 women with newly diagnosed non-insulin-dependent diabetes mellitus, and in 13 healthy control men and 13 women. The diabetic men had lower peak filling rate normalized to mitral stroke volume than the control men (mean +/- standard error of the mean, 4.2 +/- 0.1 vs 4.9 +/- 0.3 stroke volume/s, p less than 0.01). The diabetic women had increased LV mass (102 +/- 12 vs 86 +/- 8 g/m2, p less than 0.01) and decreased fractional shortening (34 +/- 1 vs 38 +/- 1%, p less than 0.05) when compared with control women. At 3 and 15 months, 23 diabetic men and 15 women were reexamined. Concomitantly with decreasing blood glucose levels, fractional shortening improved mainly during the first 3 months and was significantly higher in both diabetic men (36 +/- 2 vs 30 +/- 2%, p less than 0.05) and women (38 +/- 1 vs 34 +/- 1%, p less than 0.05) at 15 months than at baseline. In the diabetic men, peak filling rate increased from 4.3 +/- 0.1 stroke volume/s at baseline to 4.8 +/- 0.2 stroke volume/s at 15 months (p less than 0.05). At 15 months, peak filling rate was correlated (r = 0.61, p less than or equal to 0.001) with autonomic nervous function assessed as heart rate variability during deep breathing test in diabetic men who also showed an inverse correlation between LV hypertrophy and heart rate variability throughout the follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left ventricular systolic function in middle-aged patients with diabetes mellitus

In cross-sectional studies of asymptomatic diabetic patients, multiple abnormalities in left ventricular (LV) function have been found. Long-term significance of these abnormalities is unknown because follow-up studies have not been previously performed. LV ejection fraction (EF) by radionuclide angiocardiography was examined in middle-aged control Subjects (n = 44), in patients with insulin-dependent (IDDM) (n = 32) and non-insulin-dependent (NIDDM) (n = 32) diabetes mellitus at baseline and after 4-year follow-up. At baseline, all study subjects were free from cardiovascular disease. LVEF at rest did not differ between the groups at baseline. The decrease in LVEF at rest during follow-up was 1.1 ± 1.1% (mean ± SEM) in control subjects, 3.1 ± 1.3% (p = NS, compared with control subjects) in patients with IDDM, and 7.2 ± 1.4% (p <0.01) in patients with NIDDM. At follow-up examination, abnormally low LVEF at rest (<50%) was found in 7% of control subjects, 13% of patients with IDDM (p = NS), and in 31% of patients with NIDDM (p <0.05). Compared with control subjects, the prevalence of an abnormal LVEF response to exercise (an increase by <5%, or a decrease) was higher in diabetic groups at both examinations. This prevalence increased in control subjects from 10% at baseline to 26% at follow-up examination. In patients with IDDM, the respective increase was from 43% to 52% (p = NS, compared With control subjects), and in patients with NIDDM from 53% to 73% (p = NS). Duration and metabolic control of diabetes, presence of diabetic complications, and LVEF at rest or during exercise at baseline did not differ in either diabetic group between the patients who had normal or abnormal LVEF at rest or in response to exercise at follow-up examination. No study subject experienced clinical heart failure during follow-up, but 7% of control subjects, 37% of patients (p <0.001) with IDDM, and 34% of patients (p <0.01) with NIDDM had coronary artery disease at follow-up examination. In conclusion, LVEF at rest deteriorated significantly during 4-year follow-up in patients with NIDDM but not in patients with IDDM. A high prevalence of subclinical LV systolic dysfunction became evident both in patients with IDDM and patients with NIDDM as an abnormal LVEF response to exercise both at baseline and follow-up examinations.     

Left ventricular function in patients with type 2 diabetes mellitus

This study showed that the mean left ventricular ejection fraction, end-diastolic volume, end-systolic volume, and muscle mass are comparable in patients with type 2 diabetes mellitus to gender-matched patients who do not have diabetes mellitus, but abnormal ejection fraction is more common in men, although not in women, with diabetes mellitus than without. The ejection fraction was higher and the volumes and muscle mass were lower in women than men in the presence or absence of diabetes mellitus.     

Left ventricular filling abnormalities in non-insulin-dependent diabetes mellitus and improvement by a short-term glycemic control.

To determine whether left ventricular (LV) filling abnormalities in diabetes are associated with diabetic microangiopathy, and to evaluate the effect of a short-term glycemic control on the filling abnormalities, diastolic filling dynamics were assessed by pulsed Doppler echocardiography in 246 patients with non-insulin-dependent diabetics. Isovolumic relaxation time and the ratio of peak flow velocity of atrial filling wave to peak flow velocity of early filling wave (A/E) were significantly greater in diabetic patients than in age- and sex-matched control subjects. Diabetic patients with retinopathy had significantly greater isovolumic relaxation time and A/E values than those without retinopathy. A/E was significantly decreased 1 month after insulin treatment in those without, but not with retinopathy. It is concluded that LV diastolic filling is impaired in mildly hyperglycemic patients with non-insulin-dependent diabetes mellitus without severe complications, the abnormality being more intense in patients with retinopathy. A short-term glycemic control results in a marked decrease in abnormalities in patients without, but not with retinopathy.     

应用多普勒超声心动图评价糖尿病患者的左右心室功能

应用脉冲多普勒超声心动图对比观测84例有、无并发症的非胰岛素依赖型糖尿病（NIDDM）患者及50例正常人的左、右心室功能。结果显示：NIDDM患者的左、右心室舒张及收缩功能均减退，早期以舒张功能减退为著，继之，收缩功能受损。高血压、冠心病、微血管病变等并发症可进一步加重损害，且左、有心室舒张功能参数间有显著相关关系，而收缩功能参数相关性较差。     

Left ventricular function and wall thickness in long-term insulin-dependent diabetes mellitus: an echocardiographic study

Left ventricular function and wall thickness were evaluated in 111 type I diabetic subjects (mean age 25.5 +/- 9 years, mean duration of diabetes 13.4 +/- 6.2 years), using 2-D-derived M-mode echocardiography. Patients were carefully selected for the absence of major coronary risk factors or manifest cardiac disorders, and compared with 91 age- and sex-matched control subjects. Fractional shortening and the maximal velocity of cirumferential fibre shortening did not differ significantly between the two groups. Furthermore, no differences were found in the diastolic functional parameter of velocity of circumferential fibre extension. Posterior wall thickness was significantly increased in the diabetic patients compared to the controls (9.5 +/- 1.8 mm vs. 8.4 +/- 1.3 mm. P less than 0.01). As the thickness of the interventricular septum was also moderately increased (9.2 +/- 2.2 mm vs. 8.9 +/- 1.7 mm, NS), these findings provide evidence for an early structural change of the myocardium in young diabetic patients without clinically relevant functional consequences.     

Left ventricular function in normotensive young adults with well-controlled type 1 diabetes mellitus

The aim of this study was to determine whether early myocardial structural and functional systolic and diastolic alterations in asymptomatic and uncomplicated patients with type 1 diabetes mellitus (DM) could be detected using the new highly sensitive echocardiographic techniques of integrated backscatter and color Doppler myocardial imaging. Forty asymptomatic and uncomplicated patients with type 1 DM and 40 gender- and age-matched normal controls were studied. All patients were analyzed by conventional and new echocardiographic techniques (integrated backscatter and color Doppler myocardial imaging). Patients with DM showed reduced systolic function compared with controls, evidenced by significantly lower peak strain, strain rates, and cyclic variation indexes at the septum (p <0.0001, <0.01, and <0.001, respectively) and at the posterior wall level (p <0.0001, <0.0001, and <0.001, respectively). On receiver-operating characteristic curve analysis, systolic strain and the cyclic variation index showed the highest discriminating power for separating patients with DM and control subjects. Neither structural or ultrastructural nor diastolic functional abnormalities were detected. On univariate regression analysis, a significant inverse correlation was found for DM duration with conventional (E/A ratio) and unconventional (tissue Doppler imaging E/A ratio) indexes of diastolic function, in the absence of any correlation for systolic function. In conclusion, highly sensitive ultrasonic techniques demonstrate evidence of left ventricular systolic dysfunction in the early stage of type 1 DM, in the absence of ultrastructural and left ventricular diastolic functional abnormalities.     

Echocardiographic features of impaired ventricular function in diabetes mellitus.

In order to study left ventricular diastolic function in diabetes mellitus, simultaneous echo- and phonocardiograms were recorded in 142 diabetics (free from heart disease), 20 normal subjects, and 16 patients with coronary artery disease. The resultant traces were digitised, and left ventricular relaxation and the rate and duration of cavity dimension increase and wall thinning were determined. Diastolic variables of left ventricular function were normal in 12 young diabetics with no complications. Significantly delayed mitral valve opening relative to minimum dimension and aortic valve closure was found in all other groups of diabetics. Forty-four diabetics with severe microvascular complications had significantly reduced peak rate and prolonged duration of wall thinning and dimension increase. The abnormalities were unlike those found in subjects with coronary artery disease. The extent of microvascular complications was significantly correlated to most variables of diastolic function. This relation was maintained in 31 diabetics with significant cavity dimension increase during isovolumic relaxation (incoordinate relaxation). In 42 juvenile onset patients there was good correlation between the duration of diabetes and most variables of diastolic function. These studies show that the primary cardiac abnormality in diabetic micro-angiography is a prolonged duration and reduced rate of posterior wall thinning with impaired left ventricular dimension increase, reflecting abnormal myocardial properties.     

Left ventricular dysfunction in hypertensive patients with Type 2 diabetes mellitus.

AIMS: To characterize left ventricular function in hypertensive patients with Type 2 diabetes and normal ejection fraction, and to relate these findings to pathogenic factors and clinical risk markers. METHODS: We examined 70 hypertensive patients with Type 2 diabetes mellitus with ejection fraction > 0.55 and fractional shortening > 0.25, all without any cardiac symptoms. Thirty-five non-diabetic subjects served as control subjects. Left ventricular longitudinal function was examined by tissue Doppler derived myocardial strain rate and peak systolic velocities. RESULTS: Hypertensive patients with diabetes had a significantly higher systolic strain rate (-1.1 +/- 0.3 s(-1) vs. -1.6 +/- 0.3 s(-1), P < 0.001) and lower systolic peak velocities (3.3 +/- 1.0 vs. 5.6 +/- 1.0 cm/s, P < 0.001) compared with control subjects. Myocardial systolic strain rate correlated significantly to left ventricular mass (r = 0.40, P < 0.01) and to both HbA1c (r = 0.43, P < 0.01), and fructosamine (r = 0.40, P < 0.01), but was not related to serum levels of carboxymethyllysine, albuminuria, blood pressure (dipping/non-dipping), or oral hypoglycaemic therapy. Patients with diastolic dysfunction had significantly higher levels of urine albumin [21.0 (5-2500) mg/l, vs. 9.5 (1-360), P < 0.01], heart rate (78 +/- 13 vs. 67 +/- 10 b.p.m., P < 0.005), and seated diastolic blood pressure (85 +/- 6 vs. 81 +/- 7 mmHg, P < 0.05) and non-dipping diastolic blood pressure was more frequent. CONCLUSIONS: Long axis left ventricular systolic function was significantly decreased in hypertensive patients with Type 2 diabetes mellitus, and is associated with hyperglycaemia and left ventricular hypertrophy. Diastolic dysfunction was closely related to increased diastolic blood pressure, non-dipping and increased urinary albumin excretion.     

Left ventricular hypertrophy in hypertension. Part I. Criteria of diagnosis and prevalence

Possibilities of electrocardiography, echocardiography and magnetic resonance tomography for diagnosis of left ventricular hypertrophy are reviewed and various criteria of left ventricular hypertrophy compared. Literature data concerning prevalence of left ventricular hypertrophy in different populations are presented and dependence of reported prevalences of left ventricular hypertrophy on diagnostic technique and criteria is demonstrated. Criteria of dynamic changes of left ventricular mass are also discussed.     

Left ventricular function before and after kidney transplantation. A prospective study in patients with juvenile-onset diabetes mellitus

The aim of the present investigation was to discover whetherdisturbed left ventricular (LV) function limits renal replacementtherapy in patients with juvenile onset diabetes mellitus. Seventeenpatients given functioning kidney grafts were studied non-invasively(M-mode echocardiography, apexcardiography, phonocardiography)before renal transplant and an average of six, 13 and 44 monthsafter transplant. The main pretransplant findings were pronouncedLV hypertrophy with impaired diastolic LV function (prolongedrelaxation time + signs of decreased LV distensibility) anda hyperdynamic circulation. Most of these abnormalities were significantly less severe aftersuccessful kidney transplantation. LV mass decreased by 37%44 months after transplant (p<0.01) and LV diastolic andsystolic volumes decreased with a subsequent increase in ejectionfraction from 0.65 to 0.78 (p<0.01). The LV distensibilityand filling pattern improved significantly while the prolongedrelaxation time was unchanged. These findings imply that pretransplant disturbances in LV functionare related more to factors such as hypertension, volume overloadand uraemia than to diabetes per se because no pronounced improvementin the metabolic disorder resulting from diabetes can be expected,even after the most successful transplant. Disturbed LV functionshould not, therefore, exclude uraemic diabetics from renalreplacement.     

Left ventricular diastolic function in diabetes mellitus type 2 patients: correlation with heart rate and its variability

Aims

To assess the prevalence of left ventricular diastolic dysfunction in a population of patients with type 2 diabetes mellitus; to determine correlation of diastolic dysfunction with heart rate and its variability.

Methods

The study included 202 patients with type 2 diabetes mellitus. Echocardiography was performed with special reference to diastolic function, and heart rate variability was analysed using standard deviation of normal RR intervals, root mean square of successive differences and percentage of successive R–R intervals greater than 50 ms (pNN 50 %) in a 24-h electrocardiogram recording.

Results

Diastolic dysfunction is present in 79 % of type 2 diabetes mellitus patients: grade 1 in 52 %, grade 2 in 26 % and grade 3 in 1 % of patients. The subjects with grade 1 diastolic dysfunction had a statistically significantly higher heart rate variability compared with those with grade 2 diastolic dysfunction (LSD, post hoc test, p = 0.001). In the group with diastolic dysfunction, grade 2 reduced heart rate variability was recorded in 83 % of patients (37 and 7 % for grade 1 and normal diastolic function). An increase in the severity of diastolic dysfunction was associated with decreased heart rate variability and increased heart rate.

Conclusion

Progression of diastolic dysfunction is associated with a significantly greater prevalence of reduced heart rate variability, which is accompanied by increased heart rate.     

Left ventricular diastolic dysfunction in patients with chronic renal failure: impact of diabetes mellitus.

AIMS: Left ventricular (LV) hypertrophy and LV diastolic dysfunction are cardiac changes commonly observed in patients with chronic renal failure (CRF) as well as hypertension. Although the impairment of LV diastolic function in patients with diabetes mellitus has been shown, little is known about the specific effect of diabetes on LV diastolic function in patients with CRF. The present study was designed to investigate the impact of diabetic nephropathy on LV diastolic dysfunction, independent of LV hypertrophy, in CRF patients. METHODS: In 67 patients with non-dialysis CRF as a result of chronic glomerulonephritis (n = 33) or diabetic nephropathy (n = 34), and 134 hypertensive patients with normal renal function, two-dimensional and Doppler echocardiographic examinations were performed, and LV dimension, mass, systolic function, and diastolic function were evaluated. RESULTS: LV mass was increased and LV diastolic dysfunction was advanced in subjects with CRF compared with hypertensive controls. In the comparison of echocardiographic parameters between the two groups of CRF patients, i.e. chronic glomerulonephritis and diabetic nephropathy groups, all indices of LV diastolic function were more deteriorated in the diabetic nephropathy group than in the chronic glomerulonephritis group, although LV structure including hypertrophy and systolic function did not differ between the groups. In a multiple regression analysis, the presence of diabetes (i.e. diabetic nephropathy group) was a significant predictor of LV diastolic dysfunction in CRF subjects, independent of other influencing factors such as age, blood pressure, renal function, anaemia and LV hypertrophy. CONCLUSION: The present findings suggest that LV diastolic dysfunction, independent of LV hypertrophy, is specifically and markedly progressed in patients with CRF as a result of diabetic nephropathy.