Left ventricular diastolic dysfunction: the missing window for early intervention in diabetic cardiomyopathy

perspective, DCM may be better conceptualized as continuous disease within which 45 LVDD represents earliest clinically meaningful stage. This LVDD-centered framework shifts 46 diagnostic emphasis away from end-stage failure toward early impairment, 47 thereby enabling the of high-risk before irreversible myocardial remodeling occurs. 49The close relationship between LVDD and HFpEF supports the clinical relevance of 50 concept. A growing body of suggests that DCM represents a major pathogenic contributor to the of HFpEF [6] . Many of the characteristic features of HFpEF, 52 including myocardial fibrosis, endothelial dysfunction, chronic low-grade inflammation, and 53 reduced ventricular compliance, are already present during the stage of LVDD in patients with 54 diabetes [7] . Accordingly, LVDD may represent a preclinical stage along the trajectory toward 55HFpEF, identifying a critical therapeutic window during which disease progression may still be 56 modifiable. Failure to recognize and intervene at this stage may allow continued myocardial 57 remodeling, ultimately leading to irreversible structural changes and progression to overt heart 58 failure. 59Despite its clinical relevance, systematic assessment of diastolic function remains 60 underutilized in the routine evaluation of patients with type 2 diabetes. Conventional 61 echocardiographic parameters, including the E/e′ ratio, left atrial volume index, and tricuspid 62 regurgitation velocity, provide important information regarding left ventricular diastolic function [8] . 63In addition, advanced imaging modalities such as speckle-tracking echocardiography, left atrial 64 strain analysis, and cardiac magnetic resonance imaging demonstrate greater sensitivity in 65 detecting subclinical myocardial dysfunction [9] .