Abstract
Diabetic cardiomyopathy has been defined as “a distinct entity characterized by the presence of abnormal myocardial performance or structure in the absence of epicardial coronary artery disease, hypertension, and significant valvular disease”. The diagnosis stems from the detection of myocardial abnormalities and the exclusion of other contributory causes of cardiomyopathy. It rests on non-invasive imaging techniques which can demonstrate myocardial dysfunction across the spectra of clinical presentation. The presence of diabetes is associated with an increased risk of developing heart failure, and the 75% of patients with unexplained idiopathic dilated cardiomyopathy were found to be diabetic. Diabetic patients with microvascular complications show the strongest association between diabetes and cardiomyopathy, an association that parallels the duration and severity of hyperglycemia. Metabolic abnormalities (that is hyperglycemia, hyperinsulinemia, and hyperlipemia) can lead to the cellular alterations characterizing diabetic cardiomyopathy (that is myocardial fibrosis and/or myocardial hypertrophy) directly or indirectly (that is by means of renin-angiotensin system activation, cardiac autonomic neuropathy, alterations in calcium homeostasis). Moreover, metabolic abnormalities represent, on a clinical ground, the main therapeutic target in the patients with diabetes since the diagnosis of diabetes is made. Since diabetic cardiomyopathy is highly prevalent in the asymptomatic type 2 diabetic patients, screening for its presence at the earliest stage of development can lead to prevent the progression to chronic heart failure. The most sensitive test is standard echocardiogram, while a less expensive pre-screening method is the detection of microalbuminuria.
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Appendix
Appendix
Diastolic heart failure (heart failure with normal ejection fraction)
Asymptomatic diabetic cardiomyopathy may progress to a symptomatic stage (typical symptoms and/or signs of heart failure but with a normal EF). This condition is term “heart failure with normal ejection fraction (HfnEF) or diastolic failure”, as abnormalities in diastolic function are presumed to underlie the clinical findings. According to the Guidelines [81], HfnEF is defined as signs and/or symptoms of heart failure, a normal ejection fraction (>50%), and a non-dilated left ventricle (i.e., normal left ventricular end-diastolic volume index <97 ml/m²). In addition, objective evidence of left ventricular relaxation or filling abnormalities must be obtained. In the “Candsartan I heart failure assessment of reduction in mortality and morbidity (CHARM) preserved” [82], moderate/severe diastolic dysfunction was associated with a poor prognosis. As recently reported, diabetes is an independent predictor of increased mortality in patients with heart failure and preserved EF [83].
The mechanism(s) that induce the progression from asymptomatic diabetic cardiomyopathy to symptomatic heart failure are so far scarcely understood. A recent clinical study [84] identified left atrial dilatation, impaired left atrial contractile function, and the extent of left ventricular hypertrophy as major factors in the transition from hypertensive heart disease to symptomatic heart failure.
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Tarquini, R., Lazzeri, C., Pala, L. et al. The diabetic cardiomyopathy. Acta Diabetol 48, 173–181 (2011). https://doi.org/10.1007/s00592-010-0180-x
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DOI: https://doi.org/10.1007/s00592-010-0180-x