Menzies Institute for Medical Research, Hobart, Australia.
Menzies Institute for Medical Research, Hobart, Australia; Baker Heart and Diabetes Institute, Melbourne, Australia.
JACC Cardiovasc Imaging. 2018 Oct;11(10):1390-1400. doi: 10.1016/j.jcmg.2018.03.015. Epub 2018 May 16.
OBJECTIVES: This study sought to identify whether impaired global longitudinal strain (GLS), diastolic dysfunction (DD), or left atrial enlargement (LAE) should be added to stage B heart failure (SBHF) criteria in asymptomatic patients with type 2 diabetes mellitus. BACKGROUND: SBHF is a precursor to clinical heart failure (HF), and its recognition justifies initiation of cardioprotective therapy. However, original definitions of SBHF were based on LV hypertrophy and impaired ejection fraction. METHODS: Patients with asymptomatic type 2 diabetes mellitus ≥65 years of age (age 71 ± 4 years; 55% men) with preserved ejection fraction and no ischemic heart disease were recruited from a community-based population. All underwent a standard clinical evaluation, and a comprehensive echocardiogram, including assessment of left ventricular hypertrophy (LVH), LAE, DD (abnormal E/e'), and GLS (<16%). Over a median follow-up of 1.5 years (range 0.5 to 3), 20 patients were lost to follow-up, and 290 individuals were entered into the final analyses. RESULTS: In this asymptomatic group, LV dysfunction was identified in 30 (10%) by DD, 68 (23%) by LVH, 102 (35%) by LAE, and 68 (23%) by impaired GLS. New-onset HF developed in 45 patients and 4 died, giving an event rate of 112/1,000 person-years. Survival free of the composite endpoint (HF and death) was about 1.5-fold higher in patients without a normal, compared with an abnormal echocardiogram. LVH, LAE, and GLS <16% were associated with increased risk of the composite endpoint, independent of ARIC risk score and glycosylated hemoglobin, but abnormal E/e' was not. The addition of left atrial volume and GLS provided incremental value to the current standard of clinical risk (ARIC score) and LVH. In a competing-risks regression analysis, LVH (hazard ratio: 2.90; p < 0.001) and GLS <16% (hazard ratio: 2.26; p = 0.008), but not DD and LAE were associated with incident HF. CONCLUSIONS: Subclinical left ventricular systolic dysfunction is prevalent in asymptomatic elderly patients with type 2 diabetes mellitus, and impaired GLS is independent and incremental to LVH in the prediction of incident HF.
目的：本研究旨在探讨对于无症状 2 型糖尿病患者，是否应将局部纵向应变（GLS）受损、舒张功能障碍（DD）或左心房扩大（LAE）加入到 B 期心力衰竭（SBHF）标准中。
背景：SBHF 是临床心力衰竭（HF）的前兆，识别 SBHF 可证明启动心脏保护治疗的合理性。然而，SBHF 的最初定义是基于左心室肥厚和射血分数降低。
方法：本研究纳入了年龄≥65 岁（71±4 岁；55%为男性）、无缺血性心脏病且射血分数正常的社区人群中无症状 2 型糖尿病患者。所有患者均接受了标准的临床评估以及全面的超声心动图检查，包括左心室肥厚（LVH）、LAE、DD（异常 E/e'）和 GLS（<16%）的评估。中位随访时间为 1.5 年（0.5-3 年），共有 20 例患者失访，290 例患者纳入最终分析。
结果：在这个无症状的患者群体中，通过 DD 发现 30 例（10%）存在左室功能障碍，68 例（23%）存在 LVH，102 例（35%）存在 LAE，68 例（23%）存在 GLS 降低。45 例患者新发 HF，4 例死亡，发生率为 112/1000 人年。与超声心动图异常的患者相比，无正常超声心动图的患者发生复合终点（HF 和死亡）的风险低约 1.5 倍。LVH、LAE 和 GLS<16%与复合终点风险增加相关，独立于 ARIC 风险评分和糖化血红蛋白，但异常 E/e'则不然。左心房容积和 GLS 的加入为当前临床风险（ARIC 评分）和 LVH 的标准提供了额外的价值。在竞争风险回归分析中，LVH（风险比：2.90；p<0.001）和 GLS<16%（风险比：2.26；p=0.008），而非 DD 和 LAE，与 HF 事件相关。
结论：亚临床左心室收缩功能障碍在无症状的老年 2 型糖尿病患者中较为常见，GLS 受损与 LVH 一样，是 HF 事件的独立且增量预测因子。
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