Subclinical Alterations of Cardiac Mechanics Present Early in the Course of Pediatric Type 1 Diabetes Mellitus: A Prospective Blinded Speckle Tracking Stress Echocardiography Study

Abstract

Diabetic cardiomyopathy substantially accounts for mortality in diabetes mellitus. The pathophysiological mechanism underlying diabetes-associated nonischemic heart failure is poorly understood and clinical data on myocardial mechanics in early stages of diabetes are lacking. In this study we utilize speckle tracking echocardiography combined with physical stress testing in order to evaluate whether left ventricular (LV) myocardial performance is altered early in the course of uncomplicated type 1 diabetes mellitus (T1DM). 40 consecutive asymptomatic normotensive children and adolescents with T1DM (mean age 11.5 ± 3.1 years and mean disease duration 4.3 ± 3.5 years) and 44 age- and gender-matched healthy controls were assessed using conventional and quantitative echocardiography (strain and strain rate) during bicycle ergometer stress testing. Strikingly, T1DM patients had increased LV longitudinal (p = 0.019) and circumferential (p = 0.016) strain rate both at rest and during exercise (p = 0.021). This was more pronounced in T1DM patients with a longer disease duration (p = 0.038). T1DM patients with serum HbA1c > 9% showed impaired longitudinal (p = 0.008) and circumferential strain (p = 0.005) and a reduced E/A-ratio (p = 0.018). In conclusion, asymptomatic T1DM patients have signs of hyperdynamic LV contractility early in the course of the disease. Moreover, poor glycemic control is associated with early subclinical LV systolic and diastolic impairment.

Subclinical left ventricular systolic and diastolic dysfunction in type 1 diabetic children and adolescents with good metabolic control

“…Our study TDI results showed that duration of diabetes had negative impact on the LV diastolic and systolic functions. On the other hand, all pediatric studies using 2DSTE have reported negative correlation between glycemic control and LV strains (LS, CS, and RS) but no correlation between duration of T1DM and LV strains . In the present study, we found negative correlation between duration of T1DM and LV strains which agree with Nakai et al.…”

“…Altun et al reported in addition to diastolic dysfunction, impaired LV longitudinal and radial function (global LS and RS) in asymptomatic children and adolescents with type 1 DM who have normal LV ejection fraction. On the other hand, Hensel et al performed speckle tracking echocardiography in combination with ergometer stress testing in asymptomatic normotensive pediatric patients with uncomplicated T1DM and healthy controls. They found increased circumferential and longitudinal strain rate in T1DM patients both at rest and during exercise test.…”

“…On the other hand, recent investigations have found that left ventricular longitudinal myocardial systolic dysfunction, rather than diastolic dysfunction, should be considered the first sign of a preclinical diabetic cardiomyopathy in adults . Previous studies in diabetic children and adolescents had also shown subclinical left ventricular systolic and diastolic dysfunction using conventional (standard two‐dimensional and Doppler echocardiography and tissue Doppler imaging) and nonconventional (two‐dimensional speckle tracking echocardiography) echocardiographic tools . But the relationship between these subclinical LV systolic and/or diastolic dysfunction and glycemic control and duration of diabetes is not well understood in children and adolescents.…”

Three‐dimensional speckle tracking echocardiography: Is it the magic wand in the diagnosis of subclinical myocardial dysfunction in children with type 1 diabetes mellitus?

“…Pathophysiology of diabetes associated cardiac impairment is not fully understood yet but can be attributed to suppressed glucose oxidation, impaired calcium homeostasis, high level of oxidative stress, altered intracellular signaling, activation of renin‐angiotensin system, enhanced fatty acid metabolism, cardiac autonomic dysfunction, and pathological remodeling …”

Progeria of the Heart in Type 1 Diabetic Children?

“…Recently, two-dimensional speckle tracking echocardiographic studies to demonstrate LV mechanical dysfunction more sensitively and a few studies have published in children with type 1 DM 8)9). Hensel et al10) reported that asymptomatic type 1 DM children had signs of hyperdynamic LV contractility early in the course of the disease. And, poor glycemic control was associated with early subclinical LV systolic and diastolic impairment.…”