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Diabetic cardiomyopathy—fact or fiction?

Diabetische Kardiomyopathie – Fakt oder Fiktion?

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Abstract

Epidemiologic as well as clinical studies confirm the close link between diabetes mellitus and heart failure. Diabetic cardiomyopathy (DCM) is still a poorly understood “entity”, however, with several contributing pathogenetic factors which lead in different stages of diabetes to characteristic clinical phenotypes. Hyperglycemia with a shift from glucose metabolism to increased beta-oxidation and consecutive free fatty acid damage (lipotoxicity) to the myocardium, insulin resistance, renin-angiotensin-aldosterone system (RAAS) activation, altered calcium homeostasis and structural changes from the natural collagen network to a stiffer matrix due to advanced glycation endproduct (AGE) formation, hypertrophy and fibrosis contribute to the respective clinical phenotypes of DCM.

We propose the following classification of cardiomyopathy in diabetic patients:

  1. a)

    Diastolic heart failure with normal ejection fraction (HFNEF) in diabetic patients often associated with hypertrophy without relevant hypertension. Relevant coronary artery disease (CAD), valvular disease and uncontrolled hypertension are not present. This is referred to as stage 1 DCM.

  2. b)

    Systolic and diastolic heart failure with dilatation and reduced ejection (HFREF) in diabetic patients excluding relevant CAD, valvular disease and uncontrolled hypertension as stage 2 DCM.

  3. c)

    Systolic and/or diastolic heart failure in diabetic patients with small vessel disease (microvascular disease) and/or microbial infection and/or inflammation and/or hypertension but without CAD as stage 3 DCM.

  4. d)

    If heart failure may also be attributed to infarction or ischemia and remodeling in addition to stage 3 DCM the term should be heart failure in diabetes or stage 4 DCM.

These clinical phenotypes of diabetic cardiomyopathy can be separated by biomarkers, non-invasive (echocardiography, cardiac magnetic resonance imaging) and invasive imaging methods (levocardiography, coronary angiography) and further analysed by endomyocardial biopsy for concomitant viral infection. The role of specific diabetic drivers to the clinical phenotypes, to macro- and microangiopathy as well as accompanying risk factors or confounders, e.g. hypertension, autoimmune factors or inflammation with or without viral persistence, need to be identified in each individual patient separately. Thus hyperglycemia, hyperinsulinemia and insulin resistance as well as lipotoxicity by free fatty acids (FFAs) are the factors responsible for diabetic cardiomyopathy. In stage 1 and 2 DCM diabetic cardiomyopathy is clearly a fact. However, precise determination of to what degree the various underlying pathogenetic processes are responsible for the overall heart failure phenotype remains a fiction.

Zusammenfassung

Diabetes mellitus und Herzinsuffizienz treten häufig gemeinsam auf. Aus der Koinzidenz wird mit dem Begriff diabetische Kardiomyopathie (DCM) ein Zusammenhang beschrieben, der hinsichtlich Ätiologie, Pathogenese und klinischem Phänotyp bislang nur unzureichend präzisiert ist. Hyperglykämie bei gleichzeitiger Insulinresistenz führt zu einer Hochregulation der β-Oxidation. Freie Fettsäuren (FFA) decken bis zu 90% des myokardialen Energiebedarfs, anders als beim Gesunden, bei dem der Anteil der FFA nur 50% ausmacht. Die intramyokardiale FFA-Akkumulation führt zu Lipotoxizität und zu einer gestörten Kalziumhomöostase, die Bindung der FFAs an interstitielles und perivaskulären Kollagen zu „advanced glycation endproducts“ (AGE) und damit zu vermehrter Steifigkeit, Hypertrophie und additiver Fibrose. Der Diabetes mellitus umfasst als weitere Folge mikrovaskuläre Veränderungen („small vessel disease“) sowie eine Prädisposition für Infektionen und autoimmune, inflammatorische Prozesse, die den Phänotyp einer DCM ebenso prägen können wie eine begleitende arterielle Hypertonie oder eine koronare Herzerkrankung.

Wir schlagen eine Klassifikation vor, die der Pathogenese, der zeitlichen Entwicklung und dem klinischen wie hämodynamischen Phänotyp Rechnung trägt:

DCM-Stufe 1: Diastolische Herzinsuffizienz bei Diabetespatienten mit normaler Ejektionsfraktion („heart failure with normal ejection fraction“, HFNEF). Hier überwiegt häufig eine Hypertrophie ohne Hochdruck.

DCM-Stufe 2: Systolische und diastolische Herzinsuffizienz mit optionaler linksventrikulärer Dilatation, aber reduzierter Ejektionsfraktion (<50%) als HFREF („heart failure with reduced ejection fraction“).

DCM-Stufe 3: Systolische und diastolische Herzinsuffizienz (wie Stufe 2), aber mit mehreren additiven, nur indirekt diabetesvermittelten Begleiterkrankungen, wie Mikrovaskulopathie, myokardialer Infektion/Inflammation oder arterieller Hypertonie.

DCM-Stufe 4: Herzinsuffizienz bei Patienten mit Diabetes mellitus, d. h. DCM-Stufe 3, zusätzlich eine koronare Herzerkrankung mit Infarkt und Remodelling.

Die Charakterisierung der vier DCM-Formen erfolgt mit den serologischen Biomarkern der Herzinsuffizienz (BNP, NTproBNP), der Nekrose (Troponine) und der Fibrose (MMPs und TIMPs), mit nichtinvasiver Bildgebung (Echokardiographie, Doppler/TDI, Kardio-MRT) und invasiver Katheterdiagnostik einschließlich Koronarangiographie und Endomyokardbiopsie. Die DCM ist für die Formen 1 und 2 etablierter Fakt. Doch den jeweiligen Anteil pathogenetischer Faktoren aller 4 DCM-Stufen an der Herzinsuffizienz/Kardiomyopathie des jeweiligen Patienten mit diesen Methoden quantitativ bestimmen zu können, bleibt eine Fiktion.

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  1. Klinik für Innere Medizin-Kardiologie, UKGM GmbH und Philipps-Universität Marburg, Baldingerstr., 35043, Marburg, Deutschland

    B. Maisch, P. Alter & S. Pankuweit

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Maisch, B., Alter, P. & Pankuweit, S. Diabetic cardiomyopathy—fact or fiction?. Herz 36, 102–115 (2011). https://doi.org/10.1007/s00059-011-3429-4

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