The development of heart failure in patients with diabetes mellitus and pre-clinical diastolic dysfunction a population-based study

Abstract

Objectives: The purpose of this study was to evaluate the outcomes of pre-clinical diastolic dysfunction in diabetic patients.

Background: Studies have reported a high prevalence of pre-clinical diastolic dysfunction among patients with diabetes mellitus.

Methods: We identified all diabetic patients with a tissue Doppler imaging assessment of diastolic function in Olmsted County, Minnesota, from 2001 to 2007. Diastolic dysfunction was defined as a passive transmitral left ventricular (LV) inflow velocity to tissue Doppler imaging velocity of the medial mitral annulus during passive filling (E/e') ratio >15. The main outcome was the development of heart failure (HF). Secondary outcomes were the development of atrial fibrillation and death.

Results: Overall, 1,760 diabetic patients with a tissue Doppler echocardiographic assessment of diastolic function were identified; 411 (23%) patients had diastolic dysfunction. Using multivariable Cox's proportional hazard modeling, we determined that for every 1-U increase in the passive transmitral LV inflow velocity to tissue Doppler imaging velocity of the medial mitral annulus during passive filling (E/e') ratio, the hazard ratio (HR) of HF increased by 3% (HR: 1.03; 95% confidence interval [CI]: 1.01 to 1.06; p = 0.006) and that diastolic dysfunction was associated with the subsequent development of HF after adjustment for age, sex, body mass index, hypertension, coronary disease, and echocardiographic parameters (HR: 1.61; 95% CI: 1.17 to 2.20; p = 0.003). The cumulative probability of the development of HF at 5 years for diabetic patients with diastolic dysfunction was 36.9% compared with 16.8% for patients without diastolic dysfunction (p < 0.001). Furthermore, diabetic patients with diastolic dysfunction had a significantly higher mortality rate compared with those without diastolic dysfunction.

Conclusions: We demonstrated that an increase in the passive transmitral LV inflow velocity to tissue Doppler imaging velocity of the medial mitral annulus during passive filling (E/e') ratio in diabetic patients is associated with the subsequent development of HF and increased mortality independent of hypertension, coronary disease, or other echocardiographic parameters.

Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1. Kaplan-Meier Analysis of Diastolic Dysfunction and Subsequent Heart Failure in Diabetic Patients

Diastolic dysfunction defined as an E/e′ > 15 is predictive of heart failure in Kaplan-Meier analysis. The cumulative probability of the development of heart failure for diabetic patients with diastolic dysfunction is 13.1% at 1 year and 36.9% at 5 years compared to 5.2% at 1 year and 16.8% at 5 years for diabetic patients without diastolic dysfunction.

Figure 2. Kaplan-Meier Analysis of Diastolic Dysfunction and Death in Diabetic Patients

Diastolic dysfunction defined as an E/e′ ratio > 15 is predictive of death in Kaplan-Meier analysis. The cumulative probability of death for diabetic patients with diastolic dysfunction is 6.9% at 1 year and 30.8% at 5 years compared to 3.1% at 1 year and 12.1% at 5 years for diabetic patients without diastolic dysfunction.