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. 2024 Winter;26(2):101073.
doi: 10.1016/j.jocmr.2024.101073. Epub 2024 Aug 2.

Occult coronary microvascular dysfunction and ischemic heart disease in patients with diabetes and heart failure

Noor Sharrack  1 , Louise A E Brown  1 , Jonathan Farley  1 , Ali Wahab  1 , Nicholas Jex  1 , Sharmaine Thirunavukarasu  1 , Amrit Chowdhary  1 , Miroslawa Gorecka  1 , Wasim Javed  1 , Hui Xue  2 , Eylem Levelt  1 , Erica Dall'Armellina  1 , Peter Kellman  2 , Pankaj Garg  3 , John P Greenwood  1 , Sven Plein  1 , Peter P Swoboda  4
Affiliations

Occult coronary microvascular dysfunction and ischemic heart disease in patients with diabetes and heart failure

Noor Sharrack et al. J Cardiovasc Magn Reson. 2024 Winter.

Abstract

Background: Patients with diabetes mellitus (DM) and heart failure (HF) have worse outcomes than normoglycemic HF patients. Cardiovascular magnetic resonance (CMR) can identify ischemic heart disease (IHD) and quantify coronary microvascular dysfunction (CMD) using myocardial perfusion reserve (MPR). We aimed to quantify the extent of silent IHD and CMD in patients with DM presenting with HF.

Methods: Prospectively recruited outpatients undergoing assessment into the etiology of HF underwent in-line quantitative perfusion CMR for calculation of stress and rest myocardial blood flow (MBF) and MPR. Exclusions included angina or history of IHD. Patients were followed up (median 3.0 years) for major adverse cardiovascular events (MACE).

Results: Final analysis included 343 patients (176 normoglycemic, 84 with pre-diabetes, and 83 with DM). Prevalence of silent IHD was highest in DM 31% ( 26/83), then pre-diabetes 20% (17/84) then normoglycemia 17%, ( 30/176). Stress MBF was lowest in DM (1.53 ± 0.52), then pre-diabetes (1.59 ± 0.54) then normoglycemia (1.83 ± 0.62). MPR was lowest in DM (2.37 ± 0.85) then pre-diabetes (2.41 ± 0.88) then normoglycemia (2.61 ± 0.90). During follow-up, 45 patients experienced at least one MACE. On univariate Cox regression analysis, MPR and presence of silent IHD were both associated with MACE. However, after correction for HbA1c, age, and left ventricular ejection fraction, the associations were no longer significant.

Conclusion: Patients with DM and HF had higher prevalence of silent IHD, more evidence of CMD, and worse cardiovascular outcomes than their non-diabetic counterparts. These findings highlight the potential value of CMR for the assessment of silent IHD and CMD in patients with DM presenting with HF.

Keywords: Cardiovascular magnetic resonance (CMR); Coronary microvascular dysfunction (CMD); Diabetes mellitus (DM); Heart failure (HF); Myocardial blood flow (MBF); Myocardial perfusion reserve (MPR).

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Conflict of interest statement

Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Figures

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Graphical abstract
Fig. 1
Fig. 1
Stress and rest quantitative myocardial perfusion maps for three patients by glycemic status. In the normoglycemic patient, global stress perfusion is 3.0 mL/g/min, global resting perfusion is 1.0 mL/g/min, and MPR is 3. Late gadolinium enhancement (LGE) imaging demonstrates no enhancement. In the pre-diabetic patient, global stress perfusion is 1.85 mL/g/min, global resting perfusion is 0.87 mL/g/min, and MPR is 2.13. The polar maps are consistent with a diagnosis of coronary microvascular dysfunction. LGE demonstrates no enhancement. In the diabetic patient, global stress perfusion is 1.60 mL/g/min, global resting perfusion is 0.80 mL/g/min, and MPR is 2.0. The LGE demonstrates subendocardial enhancement of the mid-septum consistent with myocardial infarction in this territory. MPR myocardial perfusion reserve.
Fig. 2
Fig. 2
Associations between log-transformed HbA1c and stress MBF (left, R = −0.241, p < 0.001), rest MBF (middle, R = −0.140, p = 0.290) and MPR (right, R = −0.122, p = 0.039) with 95% confidence intervals shown in blue. The HbA1c thresholds for normoglycemia (green), pre-diabetes (orange), and diabetes (red) are shown. MBF myocardial blood flow, MPR myocardial perfusion reserve.
Fig. 3
Fig. 3
Kaplan-Meier survival curve by glycemic status. MACE major adverse cardiovascular events.
See this image and copyright information in PMC

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