Letter: Risk Factors Associated with Left Ventricular Diastolic Dysfunction in Type 2 Diabetic Patients without Hypertension (Korean Diabetes J 2010;34:40-6)

Dong-Lim Kim

doi:10.4093/kdj.2010.34.2.135

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Letter Letter: Risk Factors Associated with Left Ventricular Diastolic Dysfunction in Type 2 Diabetic Patients without Hypertension (Korean Diabetes J 2010;34:40-6): Dong-Lim Kim; Korean Diabetes Journal 2010;34(2):135-136.
DOI: https://doi.org/10.4093/kdj.2010.34.2.135
Published online: April 30, 2010

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Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea.

Corresponding author: Dong-Lim Kim. Division of Endocrinology and Metabolism, Department of Internal Medicine, Konkuk University School of Medicine, 1 Hwayang-dong, Gwangjin-gu, Seoul 143-701, Korea. dlkim@kuh.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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To the Editor: We read with interest the study by Noh et al., which demonstrated that the duration of diabetes could be a marker for left ventricular (LV) diastolic dysfunction, independent of other diastolic dysfunction-related variables in type 2 diabetic patients without hypertension or ischemic heart disease [1].

Diabetic cardiomyopathy is diabetes-associated changes in the structure and function of the myocardium that are not directly attributable to other confounding factors, such as coronary artery disease. It is characterized by a latent subclinical period, during which there is evidence of diastolic dysfunction and left ventricular hypertrophy before overt clinical deterioration and systolic failure ensue [2].

Noh's study demonstrated that diabetes duration is an independent risk factor of LV diastolic dysfunction in a Korean population with type 2 diabetes.

Noh's study included type 2 diabetic patients with normal ECG and without history of ischemic heart disease. However, many diabetic patients have asymptomatic coronary heart disease. Thus, screening patients with only past medical history and normal resting ECG could limit the value of excluding patients with ischemic heart disease. Incorporating exercise testing into patient selection could provide more ideal study subjects [3].

Previous studies reported that LV diastolic dysfunction in diabetic patients is also associated with hyperglycemia, duration of diabetes, insulin resistance, and obesity [2,4]. Noh's study showed that higher body mass index and longer duration of diabetes were associated with LV diastolic dysfunction in patients with type 2 diabetes. These findings were consistent with the previous reports. Diastolic dysfunction is believed to be the earliest functional change in diabetic cardiomyopathy and is closely correlated with glycated haemoglobin [4]. Hyperglycaemic patients demonstrate an 8% increase in the risk of developing heart failure with every 1% elevation of glycosylated hemoglobin [4]. However, in authors' study, there was no significant difference in the level of HbA1c between the two groups. The small number of study subjects is one possible explanation for the negative result. Another is relatively poor glycemic control in both groups. Comparison of LV diastolic dysfunction between patients with good glycemic control (HbA1C < 7%) and patients with poor glycemic control (HbA1C ≥ 7%) is necessary to examine the association of glycemic control and LV diastolic dysfunction.

Echocardiography was used as a tool to diagnos LV dysfunction. A recent study showed that asymptomatic diabetic patients, even with normal resting LV dimensions and function, experience exercise-induced delayed onset of LV relaxation [5]. Although the predictive value of echocardiography for LV dysfunction is good, it might have not ruled out LV dysfunction completely. Therefore, stress tests, such as treadmill or dobutamine stress echocardiography, could detect more patients with LV dysfunction.

Increased LV mass is an independent risk factor for heart failure in type 2 diabetes, and may contribute to reduced myocardial compliance [6,7]. Thus, it would be more interesting to mention the association between LV mass and heart failure in the authors' study.

Considering the high prevalence and significant morbidity and mortality of heart failure in patients with type 2 diabetes, the evaluation of cardiac function in asymptomatic diabetic patients is very important to detect and prevent heart failure.

REFERENCES

1. Noh JH, Doh JH, Lee SY, Kim TN, Lee H, Song HY, Park JH, Ko KS, Rhee BD, Kim DJ. Risk factors associated with left ventricular diastolic dysfunction in type 2 diabetic patients without hypertension. Korean Diabetes J 2010;34:40-46. Article PubMed PMC
2. Khavandi K, Khavandi A, Asghar O, Greenstein A, Withers S, Heagerty AM, Malik RA. Diabetic cardiomyopathy--a distinct disease? Best Pract Res Clin Endocrinol Metab 2009;23:347-360. Article PubMed
3. Paraskevaidis IA, Tsougos E, Panou F, Dagres N, Karatzas D, Boutati E, Varounis C, Kremastinos DT. Diastolic stress echocardiography detects coronary artery disease in patients with asymptomatic type 2 diabetes. Coron Artery Dis 2010;21:104-112. PubMed
4. Iribarren C, Karter AJ, Go AS, Ferrara A, Liu JY, Sidney S, Selby JV. Glycemic control and heart failure among adult patients with diabetes. Circulation 2001;103:2668-2673. Article PubMed
5. Mizuno R, Fujimoto S, Saito Y, Nakamura S. Exercise-induced delayed onset of left ventricular early relaxation in association with coronary microcirculatory dysfunction in patients with diabetes mellitus. J Card Fail 2010;16:211-217. Article PubMed
6. Boudina S, Abel ED. Diabetic cardiomyopathy, causes and effects. Rev Endocr Metab Disord 2010;11:31-39. Article PubMed PMC PDF
7. von Bibra H, St John Sutton M. Diastolic dysfunction in diabetes and the metabolic syndrome: promising potential for diagnosis and prognosis. Diabetologia 2010;53:1033-1045. Article PubMed PMC

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Letter: Risk Factors Associated with Left Ventricular Diastolic Dysfunction in Type 2 Diabetic Patients without Hypertension (Korean Diabetes J 2010;34:40-6)

Korean Diabetes J. 2010;34(2):135-136. Published online April 30, 2010

DOI: https://doi.org/10.4093/kdj.2010.34.2.135

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