What question did this study set out to answer?

This research aims to investigate the relationship between diabetes and myocardial extracellular volume fraction, and its implications for mortality and heart failure.

April 25, 2026Open Access

Myocardial extracellular volume fraction quantified by cardiovascular magnetic resonance is increased in diabetes and associated with mortality and incident heart failure admission

Key Result

Myocardial extracellular volume fraction is increased in diabetes and is associated with mortality and incident heart failure hospitalization.

Key Points

This research aims to investigate the relationship between diabetes and myocardial extracellular volume fraction, and its implications for mortality and heart failure.
Enrolled 1176 patients referred for cardiovascular magnetic resonance without amyloidosis.
Computed extracellular volume fraction from haematocrit and myocardial T1 measures pre- and post-contrast.
Used linear and Cox regression analyses to evaluate the relationship between ECV, diabetes, and clinical outcomes.
Diabetic individuals had a median extracellular volume fraction of 30.2% compared to 28.1% in non-diabetics (P < 0.001).
Renin-angiotensin-aldosterone system blockade was associated with lower extracellular volume fraction (P = 0.028).
Every 3% increase in extracellular volume fraction was linked to a 52% higher risk of mortality/hospitalization for heart failure (HR: 1.52, 95% CI: 1.21-1.89).

Structured PICO

Is myocardial extracellular volume fraction quantified by cardiovascular magnetic resonance associated with mortality and incident heart failure admission in diabetic individuals?

Population

Diabetic individuals

Intervention

Cardiovascular magnetic resonance quantification of myocardial extracellular volume (ECV) fraction

Outcome

Mortality and/or incident hospitalization for heart failurehard clinical

Myocardial extracellular volume fraction measured by CMR is a detectable intermediate phenotype associated with mortality and heart failure in diabetes.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

AIMS: Diabetes may promote myocardial extracellular matrix (ECM) expansion that increases vulnerability. We hypothesized that: (i) type 2 diabetes would be associated with quantitative cardiovascular magnetic resonance (CMR) measures of myocardial ECM expansion, i.e. extracellular volume fraction (ECV); (ii) medications blocking the renin-angiotensin-aldosterone system (RAAS) would be associated with lower ECV; and (iii) ECV in diabetic individuals would be associated with mortality and/or incident hospitalization for heart failure. METHODS AND RESULTS: We enrolled 1176 consecutive patients referred for CMR without amyloidosis and computed ECV from measures of the haematocrit and myocardial and blood T1 pre- and post-contrast. Linear regression modelled ECV; Cox regression modelled mortality and/or hospitalization for heart failure. Diabetic individuals (n = 231) had higher median ECV than those without diabetes (n = 945): 30.2% (IQR: 26.9-32.7) vs. 28.1% (IQR: 25.9-31.0), respectively, P < 0.001). Diabetes remained associated with higher ECV in models adjusting for demographics, comorbidities, and medications (P < 0.001). Renin-angiotensin-aldosterone system blockade was associated with lower ECV (P = 0.028) in multivariable linear models. Over a median of 1.3 years (IQR: 0.8-1.9), 38 diabetic individuals had events (21 incident hospitalizations for heart failure; 24 deaths), and ECV was associated with these events (HR: 1.52, 95% CI: 1.21-1.89 per 3% ECV increase) in multivariable Cox regression models. CONCLUSION: Diabetes is associated with increased ECV. Extracellular volume fraction detects amelioration of ECM expansion associated with RAAS blockade, and is associated with mortality and/or incident hospitalization for heart failure in diabetic individuals. Extracellular matrix expansion may be an important intermediate phenotype in diabetic individuals that is detectable and treatable.