Myocardial Abnormalities Across the AHA/ACC Stages of Heart Failure in Patients With Diabetes

Figures

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  Figure 1. Flow Diagram of the Study Population A total of 475 diabetes mellitus (DM) participants with left ventricular ejection fraction (LVEF) were enrolled for analysis, including 89 at stage A, 220 at stage B, and 166 at stage C (heart failure with preserved ejection fraction [HFpEF]). A group of 78 healthy volunteers were recruited for comparison. MRI = magnetic resonance imaging; NT-proBNP = N-terminal pro–brain natriuretic peptide.

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  Figure 2. Left Ventricular Longitudinal Strain and Strain Rate Analysis Representative cardiac magnetic resonance studies of left ventricular longitudinal strain and strain rate images and curves from stage A/B/C heart failure in diabetes mellitus participants. Top row shows strain measurements in 2-chamber view, and bottom row shows strain curves of global longitudinal strain and strain rate. eGLSR = early diastolic global longitudinal strain rate; GLS = global longitudinal strain.

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  Figure 3. Comparison of CMR Characteristics Among 4 Groups Strain parameters were expressed as absolute values, and the lower values meant worse cardiac function. Among groups of control subjects and stage A/B/C heart failure, left atrial maximum volume index (LAVi) and left ventricular mass index (LVMi) increased with worsening heart failure in diabetes mellitus (top row). Absolute GLS, global circumferential strain (GCS) and global radial strain (GRS) values significantly decreased with progressive HF severity (Middle row). For diastolic strain rates, eGLSR and early diastolic global circumferential strain rate (eGCSR) were significant lower in both pre-heart failure and heart failure with preserved ejection fraction than in stage A heart failure and control subjects. extracellular volume fraction (ECV) was also higher in more severe patients across HF stages (Bottom row). Abbreviations as in Figures 1 and 2.

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  Figure 4. Distribution of GLS and eGLSR Across Heart Failure Stages The severity of impaired GLS and eGLSR was stratified by mean and 1 × SD in the healthy group (−17.7% ± 1.7% for GLS and 0.81 ± 0.17/s for eGLSR). In stage A heart failure, impaired eGLSR was more notable while the impairment of GLS was more severe in more advanced stages. It is suggested that the eGLSR at stage A could be a more sensitive assessment of functional impairment, whereas GLS was superior to eGLSR in assessing myocardial dysfunction at stage C. Abbreviations as in Figure 2.

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  Figure 5. Receiver-Operating Characteristic Curves for Identifying Patients With Stage A/B HF Top row shows cardiac magnetic resonance-derived left ventricular parameters for differentiation stage A from normal control (A) and stage B from stage A (B). Bottom row shows receiver-operating characteristic curves using combined parameters obtained from logistic regression analysis, and they show greater AUC than a single parameter, with an AUC of 0.843 for distinguishing stage A from control subjects (C) and an AUC of 0.844 for distinguishing stage B from A (D). eGFR = estimated glomerular filtration rate; LVEDVi = left ventricular end-diastole volume index; sGLSR = systolic global longitudinal strain rate; other abbreviations as in Figure 3.

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  Central Illustration. Characteristic Magnetic Resonance Features in Development of Heart Failure With Preserved Ejection Fraction in Diabetes Mellitus Patients The top row shows the characteristic changes of CMR features including strain analysis and myocardial fibrosis assessed by T1 mapping. The middle row demonstrated the distinct change trends in GLS, eGLSR, and ECV among 4 groups. The bottom row shows representative short-axis ECV images in DM participants with different stages of heart failure. DM = diabetes mellitus; ECV = extracellular volume fraction; eGLSR = global early-diastolic global longitudinal strain rate; GLS = global longitudinal strain; HFpEF = heart failure with preserved ejection fraction; LVEF = left ventricular ejection fraction.