Effects of diabetes mellitus on left ventricular function and remodeling in hypertensive patients with heart failure with reduced ejection fraction: assessment with 3.0 T MRI feature tracking

Abstract

Background: Heart failure with reduced ejection fraction (HFrEF) is a major health burden worldwide with high morbidity and mortality. Comorbidities of HFrEF complicate treatment and lead to poor prognosis, among which hypertension (HTN) and diabetes mellitus (DM) are common and frequently cooccur. DM was found to have additive effects on cardiac function and structure in hypertensive patients, while its effects on the HFrEF cohort in the context of HTN remain unclear.

Methods: A total of 171 patients with HFrEF were enrolled in our study, consisting of 51 HFrEF controls, 72 hypertensive HFrEF patients (HTN-HFrEF [DM-]) and 48 hypertensive HFrEF patients with comorbid DM (HTN-HFrEF [DM+]). Cardiac MRI-derived left ventricular (LV) strains, including global radial (GRPS), circumferential (GCPS) and longitudinal (GLPS) peak strain, and remodeling parameters were measured and compared among groups. The determinants of impaired LV function and LV remodeling in HFrEF patients were investigated by multivariable linear regression analyses.

Results: Despite a similar LV ejection fraction, patients in the HTN-HFrEF (DM+) and HTN-HFrEF (DM-) groups showed a higher LV mass index and LV remodeling index than those in the HFrEF control group (all p < 0.05). Compared with the HTN-HFrEF (DM-) and HFrEF control groups, the HTN-HFrEF (DM+) group exhibited the most severe GLPS impairment (p < 0.001). After adjustment for covariates in HFrEF patients, DM was found to be an independent determinant of impaired LV strains in all three directions (GRPS [β = - 0.189; p = 0.011], GCPS [β = 0.217; p = 0.005], GLPS [β = 0.237; p = 0.002]). HTN was associated with impaired GLPS (β = 0.185; p = 0.016) only. However, HTN rather than DM was associated with LV remodeling in HFrEF patients in the multivariable regression analysis (p < 0.05).

Conclusions: DM aggravated LV longitudinal dysfunction in hypertensive HFrEF patients without further changes in LV remodeling, indicating that HFrEF patients with comorbid HTN and DM may have a hidden high-risk phenotype of heart failure that requires more advanced and personalized management.

Keywords: Diabetes mellitus; Heart failure with reduced ejection fraction; Hypertension; Left ventricular dysfunction; Ventricular remodeling.

Fig. 1

Flow diagram of the study patients. HFrEF: heart failure with reduced ejection fraction; HTN: hypertension; DM: diabetes mellitus

Fig. 2

Representative cardiac MRI left ventricle pseudocolor images of long-axis four-chamber cine images at the end-systole and cardiac MRI derived global longitudinal peak strain curves of a HFrEF control patient (A, D), a hypertensive HFrEF patient (B, E), and a hypertensive HFrEF patient comorbid with diabetes mellitus (C, F)

Fig. 3

Left ventricular remodeling indices among the three groups. HFrEF: heart failure with reduced ejection fraction; HTN: hypertension; DM: diabetes mellitus; LVM: left ventricular mass

Fig. 4

Global left ventricular strain indices among the three groups. HFrEF: heart failure with reduced ejection fraction; HTN: hypertension; DM: diabetes mellitus; GRPS: global radial peak strain; GCPS: global circumferential peak strain; GLPS: global longitudinal peak strain