Heart failure predictive duet of lower extremity arterial disease and peripheral neuropathy in type 2 diabetes mellitus

Introduction Previous large prospective study has shown heart failure (HF) and peripheral arterial disease (LEAD) as the most common initial manifestations of cardiovascular disease in type 2 diabetes. Purpose This prospective single-center study aimed to determine the role of LEAD and established neurological modalities in the prediction of risk for HF and death in a cohort of individuals with type 2 diabetes mellitus (DM). Methods The study was conducted from 2008-2010 to 2022. LEAD was defined with ankle brachial pressure index (ABPI) >1.4 or <0.8 and/or continuous wave Doppler monophasic curve independently of ABPI. Diabetic neuropathy was assessed using the neuropathy disability score (NDS). The dryness of foot skin was assessed by the visual indicator plaster method (IPM). Standard transthoracic echocardiographic measurements were performed. According to ejection fraction patients were divided into: G1 group, heart failure (HF) with reduced EF<39%; G2 group, HF with mildly reduced EF 40-49%; G3 group, HF with preserved EF 50-59% and G4 group (Controls), without HF with EF 60-72%. Results A total of 117 subjects with DM, at the beginning of the investigation without a history of HF, completed the study. The mean age at the beginning of the study was 67.1±6.8 years and at the end of the follow-up period 74.7±7.7 years. Males were n=74 (62.2%). DM duration 24.9±10.9 years. During the 12-year follow-up, 62 patients developed HF: G1 19 (16%), G2 n=19 (16%), G3 n=24 (20.2%), while G4 (Controls) 57 (47.9%) remained with EF >60%. Kaplan–Meier estimates of reduced ejection fraction in participants during the study period were performed. Equality of the survivor functions between the groups stratified by LEAD and different neurological modalities was performed using the log-rank test. Present vs. absent LEAD: X2= 28.701, p < 0.001; high (≥6) vs. low (<6) NDS: X2 = 4.407, p = 0.036; abnormal vs. normal IPM: X2 = 0.523, p = 0.469. Patients in the meantime died: a total of 66 (53.7%), 63.2% in G1 and 73.7% in G2 and that was significant compared to those in G4 (died 42.2%), p 0.05 and 0.00, respectively. In G3 mortality rate was 54.2% and vs. G4 it was not significant. Multivariate Cox-regression analysis after controlling for the effect of age, gender, and DM duration demonstrated that the risk (hazard ratio, 95% confidence intervals) of death increased significantly with either: waist circumference (1.03, 1-1.16, p=0.07), NDS (2.30, 1.3-4.0, p 0.03), ischemic heart disease (2.2, 1.2-3.9, p=0.01), left ventricular end-diastolic diameter (1.08, 1.04-1.12, p=0.00) and LEAD (1.9, 1.1-3.4, p=0.02). Conclusion Positive signs of diabetic foot disease increase the risk of heart failure. Based on the data obtained, echocardiographic examination data would be indicative of the need to introduce or intensify therapies in the management of diabetes.