Albuminuria as a Clinical Marker of Subclinical Myocardial Dysfunction in Diabetes: A Systematic Review and Meta-analysis.

Background: Subclinical myocardial dysfunction is common in diabetes and may precede clinically overt heart failure by several years. Albuminuria reflects systemic microvascular injury, but its relationship with the severity of myocardial dysfunction in patients with diabetes remains uncertain. Objective: To determine whether adults with diabetes and albuminuria have greater echocardiographic evidence of subclinical myocardial dysfunction than those with diabetes and normoalbuminuria. Methods: Four electronic databases were searched from inception to March 2026 for observational studies comparing adults with diabetes and albuminuria with those with normoalbuminuria. Two reviewers independently performed study selection, data extraction, and quality assessment using the Newcastle-Ottawa Scale. Random-effects models were used to pool mean differences in global longitudinal strain (GLS), E/e', left ventricular mass index, e', and ejection fraction. Adjusted regression coefficients and odds ratios were also synthesized, and certainty of evidence was evaluated using GRADE. Results: Eighteen reports representing 17 independent cohorts were included, with eight contributing to quantitative synthesis. Absolute GLS was significantly lower in patients with albuminuria (MD, -1.38 percentage points; 95% CI, -2.13 to -0.63; P < 0.001; I² = 82%). A greater strain deficit was observed from microalbuminuria to macroalbuminuria, although formal trend analysis was not possible. E/e' was higher in albuminuric patients (MD, 1.21; 95% CI, 0.18-2.24; P = 0.021), whereas ejection fraction did not differ. Albuminuria remained independently associated with impaired strain (pooled β = 1.06; 95% CI, 0.44-1.68) and higher odds of subclinical dysfunction (OR = 5.55; 95% CI, 3.43-8.98). Conclusions: Albuminuria identifies patients with diabetes who have greater subclinical systolic and diastolic myocardial impairment despite preserved ejection fraction. Urinary albumin-to-creatinine ratio may help identify asymptomatic patients who could benefit from deformation imaging, although prospective validation is required.