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.

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.