Early predictors of myocardial disease in children and adolescents with type 1 diabetes mellitus

Review A State of Natriuretic Peptide Deficiency

Measurement of natriuretic peptides (NPs) has proven its clinical value as biomarker, especially in the context of heart failure (HF). In contrast, a state partial NP deficiency appears integral to several conditions in which lower NP concentrations in plasma presage overt cardiometabolic disease. Here, obesity and type 2 diabetes have attracted considerable attention. Other factors - including age, sex, race, genetics, and diurnal regulation - affect the NP "armory" and may leave some individuals more prone to development of cardiovascular disease. The molecular maturation of NPs has also proven complex with highly variable O-glycosylation within the biosynthetic precursors. The relevance of this regulatory step in post-translational propeptide maturation has recently become recognized in biomarker measurement/interpretation and cardiovascular pathophysiology. An important proportion of people appear to have reduced effective net NP bioactivity in terms of receptor activation and physiological effects. The state of NP deficiency, then, both entails a potential for further biomarker development and could also offer novel pharmacological possibilities. Alleviating the state of NP deficiency before development of overt cardiometabolic disease in selected patients could be a future path for improving precision medicine.

Cardiovascular biomarkers in pregnancy with diabetes and associations to glucose control

AIM

Cardiovascular disease (CVD) is a leading cause of death in both men and women. Type 1 and 2 diabetes mellitus (DM1 and DM2) are well-known risk factors for CVD. In addition, gestational diabetes mellitus (GDM) is a female sex-specific risk factor for CVD. Here, we measure circulating concentrations of cardiac troponin T (cTNT), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and growth differentiation factor 15 (GDF-15) during pregnancy-a window of time often referred to as a cardiovascular stress test for women.

METHODS

This study utilized data from 384 pregnant women: 64 with DM1, 16 with DM2, 35 with GDM and 269 euglycemic controls. Blood was predominantly sampled within a week before delivery. Cardiovascular biomarker concentrations were measured in serum using electrochemiluminescence immunoassay.

RESULT

Circulating cTnT levels were higher in women with DM1, DM2 and GDM as compared to controls, whereas NT-proBNP and GDF-15 levels were only increased in women with DM1. Glucose dysregulation, assessed by third trimester HbA1c levels, positively correlated with all three CVD biomarker levels, whereas pregestational body mass index correlated negatively with GDF-15.

CONCLUSIONS

Our results support the presence of myocardial affection in women with diabetic disorders during pregnancy. Although pregestational DM1 in this study was associated with the most adverse CVD biomarker profile, women with GDM displayed an adverse cTnT profile similar to what we found in women with pregestational DM2. This supports that women with GDM should be offered long-term intensified cardiovascular follow-up and lifestyle advice following delivery, similarly to the well-established CV follow-up of women with pregestational DM.

Association of Epicardial Fat with Diastolic and Vascular Functions in Children with Type 1 Diabetes

We aimed to examine the relationship between epicardial fat thickness (EFT) measured by echocardiography and cardiovascular functional parameters in children with type 1 diabetes mellitus (T1DM). The study included 50 type 1 diabetic children and 50 healthy subjects matched by sex, age, and body mass index. In addition to laboratory tests, all participants underwent transthoracic echocardiography for EFT, cardiac dimensions and left ventricular functions, and ultrasonographic examination for brachial artery flow-mediated dilation (FMD) response and carotid intima-media thickness (CIMT). Multivariate linear regression was used to analyze the relationship between EFT and CIMT, FMD, lateral mitral E' velocity, and mitral E/E' ratio. EFT was significantly increased in diabetic children compared with controls (P < 0.001). In comparison with controls diabetic children had significantly increased mitral A, decreased lateral mitral E', decreased mitral E/A ratio, decreased lateral mitral E'/A' ratio, and increased mitral E/E' ratio (P < 0.001). FMD response was significantly lower in diabetic group versus controls (P < 0.001) and CIMT was significantly increased in diabetics versus controls (P = 0.03). EFT was negatively correlated with lateral mitral E' velocity (r =  - 0.613, P < 0.001), positively correlated with mitral E/E' ratio (r = 0.60, P < 0.001), positively correlated with CIMT (r = 0.881, P < 0.001), and negatively correlated with FMD (r =  - 0.533, P < 0.001). By multivariate regression analysis, the EFT was independently and positively associated with CIMT mean and E/E' mean and negatively associated with FMD mean and E' mean. The cut-off point for EFT as predictor of endothelial dysfunction was 6.95 mm. Our findings suggest that children with T1DM have subclinical LV diastolic and vascular endothelial dysfunctions associated with increased EFT.

CARDEA study protocol: investigating early markers of cardiovascular disease and their association with lifestyle habits, inflammation and oxidative stress in adolescence using a cross-sectional comparison of adolescents with type 1 diabetes and healthy controls

INTRODUCTION

Little is known regarding associations between potentially modifiable lifestyle habits and early markers of cardiovascular disease (CVD) in pediatric type 1 diabetes (T1D), hindering early prevention efforts. Specific objectives are: (1) compare established risk factors (dyslipidemia, hypertension) with novel early markers for CVD (cardiac phenotype, aortic distensibility, endothelial function) in adolescents with T1D and healthy age-matched and sex-matched controls; (2) examine associations between these novel early markers with: (i) lifestyle habits; (ii) adipokines and measures of inflammation; and (iii) markers of oxidative stress among adolescents with T1D and controls, and determine group differences in these associations; (3) explore, across both groups, associations between CVD markers and residential neighbourhood features.

METHODS AND ANALYSES

Using a cross-sectional design, we will compare 100 participants aged 14-18 years with T1D to 100 healthy controls. Measures include: anthropometrics; stage of sexual maturity (Tanner stages); physical activity (7-day accelerometry); sleep and sedentary behaviour (self-report and accelerometry); fitness (peak oxygen consumption); and dietary intake (three non-consecutive 24- hour dietary recalls). Repeated measures of blood pressure will be obtained. Lipid profiles will be determined after a 12- hour fast. Cardiac structure/function: non-contrast cardiac magnetic resonance imaging (CMR) images will evaluate volume, mass, systolic and diastolic function and myocardial fibrosis. Aortic distensibility will be determined by pulse wave velocity with elasticity and resistance studies at the central aorta. Endothelial function will be determined by flow-mediated dilation. Inflammatory markers include plasma leptin, adiponectin, tumour necrosis factor alpha (TNF-α), type I and type II TNF-α soluble receptors and interleukin-6 concentrations. Measures of endogenous antioxidants include manganese superoxide dismutase, glutathione peroxidase and glutathione in blood. Neighbourhood features include built and social environment indicators and air quality.

ETHICS AND DISSEMINATION

This study was approved by the Sainte-Justine Hospital Research Ethics Board. Written informed assent and consent will be obtained from participants and their parents.

TRIAL REGISTRATION NUMBER

NCT04304729.

Comparative study of the efficacy of captopril, simvastatin, and L-carnitine as cardioprotective drugs in children with type 1 diabetes mellitus: a randomised controlled trial

OBJECTIVES

To assess the efficacy and safety of captopril, simvastatin, and L-carnitine as cardioprotective drugs in children with type 1 diabetes mellitus on different echocardiographic parameters, electrocardiographic parameter, lipid profile, and carotid intima-media thickness.

METHODS

This randomised controlled trial was conducted on 100 children with type 1 diabetes mellitus for more than 3 years during the period from September 2018 to June 2020. Fifty healthy children of matched age and sex served as a control group. The patients were randomly assigned into four groups (25 children each): no-treatment group who received no cardioprotective drug, simvastatin group who received simvastatin (10-20 mg/day), captopril group who received captopril (0.2 mg/kg/day), and L-carnitine group who received L-carnitine (50 mg/kg/day) for 4 months. Lipid profile, serum troponin I, carotid intima-media thickness, and echocardiographic examinations were performed on all included children before and after the treatment.

RESULTS

Total cholesterol and low-density lipoprotein were significantly decreased in children who received simvastatin or L-carnitine. Triglycerides significantly decreased only in children who received simvastatin. High-density lipoprotein significantly increased in simvastatin and L-carnitine groups only. Serum troponin I decreased significantly in all the three treatment groups. Carotid intima-media thickness showed no significant change in all treatment groups. Echocardiographic parameters significantly improved in simvastatin, L-carnitine, and captopril groups.

CONCLUSION

Captopril, simvastatin, and L-carnitine have a significant beneficial effect on cardiac functions in children with type 1 diabetes mellitus. However, only simvastatin and L-carnitine have a beneficial effect on the lipid profile. The drugs were safe and well tolerated.Clinical trial registration: The clinical trial was registered at www.clinicaltrial.gov (NCT03660293).

The Diabetic Cardiomyopathy: The Contributing Pathophysiological Mechanisms

Individuals with diabetes mellitus (DM) disclose a higher incidence and a poorer prognosis of heart failure (HF) than non-diabetic people, even in the absence of other HF risk factors. The adverse impact of diabetes on HF likely reflects an underlying “diabetic cardiomyopathy” (DM–CMP), which may by exacerbated by left ventricular hypertrophy and coronary artery disease (CAD). The pathogenesis of DM-CMP has been a hot topic of research since its first description and is still under active investigation, as a complex interplay among multiple mechanisms may play a role at systemic, myocardial, and cellular/molecular levels. Among these, metabolic abnormalities such as lipotoxicity and glucotoxicity, mitochondrial damage and dysfunction, oxidative stress, abnormal calcium signaling, inflammation, epigenetic factors, and others. These disturbances predispose the diabetic heart to extracellular remodeling and hypertrophy, thus leading to left ventricular diastolic and systolic dysfunction. This Review aims to outline the major pathophysiological changes and the underlying mechanisms leading to myocardial remodeling and cardiac functional derangement in DM-CMP.

Investigating potential protein markers of cardiovascular disease in children with type 1 diabetes mellitus

BACKGROUND

Type 1 diabetes mellitus (T1DM) is a metabolic disease characterized by dysglycaemia. Cardiovascular disease (CVD) is a major complication among T1DM patients and the leading cause of mortality later in life.

METHODS

The study subjects consisted of T1DM children with poor glycemic control (HbA1c > 7.5%) and healthy age and gender matched controls. Venous blood samples were collected and tested by utilizing a novel immunoassay panel with 96 protein biomarkers. Data were analyzed using non-linear regression analysis and the expression of biomarkers was compared between T1DM and healthy control groups using an unpaired student's t-test. Dynamic principal component analysis (PCA) was operated based on the differentially expressed proteins.

RESULTS

Ten T1DM children and 10 healthy controls were analyzed. Twelve CVD markers show significant differential expression between T1DM patients and healthy controls (p < 0.05). Dynamic PCA clustering based on differentially expressed proteins demonstrated an obvious clustering between the two populations.

CONCLUSIONS

This preliminary study reveals the feasibility of utilizing a novel immunoassay panel to investigate potential biomarkers for predicting incipient CVD in children with T1DM. In future, longitudinal studies are required to track the relationships between measurements of the selected protein markers and the development of CVD in T1DM patients.

Use of strain, strain rate, tissue velocity imaging, and endothelial function for early detection of cardiovascular involvement in young diabetics

Background:

Subtle structural and functional changes may precede the onset of overt global left ventricular (LV) dysfunction. Data pertaining to tissue velocity imaging (TVI)and strain imaging to assess regional myocardial function and flow mediated vasodilatation are limited in young patients with diabetes.

Materials:

Conventional echocardiography, TVI parameters along with strain (S), and strain rate (SR) were measured in 50 young diabetics (15.16 ± 2.95 years, mean HBA1c 8.15 ± 1.37 g %) and 25 controls (15.60 ± 2.51 years). Flow-mediated dilation (FMD), nitrate--mediated dilatation (NMD), and carotid intima–media thickness were also assessed.

Results:

Conventional echocardiography parameters were similar in patients and controls; however, deceleration time of the mitral inflow velocity (early deceleration time) was significantly shorter in patients when compared with controls (149.06 ± 31.66 vs. 184.56 ± 19.27 ms, P =0.001). Patients had lower strain values at the basal lateral LV (21.39 ± 4.12 vs. 23.78 ± 2.02; P =0.001), mid-lateral LV (21.43 ± 4.27 vs. 23.17 ± 1.92 P =0.02), basal septum (20.59 ± 5.28 vs. 22.91 ± 2.00; P = 0.01), and midseptum (22.06 ± 4.75 vs. 24.10 ± 1.99; P = 0.01) as compared to controls. SR at the basal and midsegments of the lateral LV wall and at the basal septum was also significantly lower in diabetic patients. Diabetic children also had endothelial dysfunction with significantly lower FMD (8.36 ± 4.27 vs. 10.57 ± 4.12, P = 0.04).

Conclusions:

LV strain indices and flow--mediated dilatation are impaired in asymptomatic children and adolescents with type 1 diabetes mellitus despite absence of overt heart failure and normal ejection fraction. Early detection of subclinical regional myocardial dysfunction by deformation analysis including strain and strain rate may be useful in the asymptomatic diabetic population.

Novel biomarkers for subtle myocardial involvement in type I diabetes mellitus

Background

Evaluation of certain biomarkers could be used to predict left ventricular (LV) and right ventricular (RV) function impairment in children with type 1 diabetes mellitus. The aim of this study was to determine the best cardiac biomarker for prediction of diabetic cardiomyopathy.

Methodology

This study was designed as case-control study. A total of 55 children with type 1 diabetes mellitus (group/G1) and 55 healthy controls (G2) were subjected to echocardiography including 3D-Speckle Tracking Echocardiography and tissue Doppler imaging for assessment of RV and LV systolic and diastolic functions. As well as HbA1c, troponin I, brain natriuretic peptide (BNP), plasma cardiotrophin (CT-1), activin-A, transforming growth factor-β, and human insulin-like growth factor binding protein-7 (IGFBP-7) measurements.

Results

Diabetic patients showed RV and LV systo-diastolic dysfunction compared to controls, the best predictor of LV systolic dysfunction was CT-1 (sensitivity: 69%, while IGFBP-7 was found to be the best predictor of RV systolic dysfunction (sensitivity: 63%). BNP was found to the best predictor of diastolic RV and LV dysfunction (sensitivity: 82% for both).

Conclusion

CT-1 has proven to be a diagnostic superiority in LV systolic dysfunction whilst BNP continues to prove every day through our study and through many others that it is the chief marker of diastolic dysfunction and HFpEF. This potential accuracy and the increasing availability of BNP in the outpatient setting make it clear that it should be used as a screening test for diabetic patients.

Cardiovascular disease in young People with Type 1 Diabetes: Search for Cardiovascular Biomarkers

Premature onset of cardiovascular disease is common in people with type 1 diabetes and is relatively understudied in youth. Several reports in adolescents and young adults with diabetes demonstrate evidence of arterial stiffness and cardiac dysfunction, yet critical gaps exist in our current understanding of the temporal progression of cardiac and vascular dysfunction in these youth, and mechanistic investigations with robust pathophysiologic assessment are lacking. This review attempts to summarize relevant cardiovascular studies concerning children, adolescents, and young adults with type 1 diabetes. We focus on imaging-based biomarkers routinely applied to youth and adults that are well-established in their ability to predict adjudicated cardiovascular outcomes, and their relevant physiologic interpretation. Particularly, we focus the attention to 1) cardiac ventricular strain imaging techniques which are known to be predictive of clinical outcomes in patients with heterogenous causes of heart failure, and 2) stiffness in large arteries, a well-established prognostic marker of cardiovascular events. We conclude that there remains an urgent need for sensitive and quantitative biomarkers to define the natural history of cardiac and vascular disease origination and progression in type 1 diabetes, and set the stage for interpreting interventional studies focused on preventing, reversing or slowing disease progression.

High-Sensitivity Cardiac Troponin-T and N-Terminal Prohormone of B-Type Natriuretic Peptide in Relation to Cardiovascular Outcomes in Type 1 Diabetes

OBJECTIVE

High-sensitivity cardiac troponin-T (hs-cTnT) and N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), biomarkers of cardiovascular disease (CVD) and heart failure, respectively, have not been widely studied in type 1 diabetes (T1D). We evaluated whether their assessment in T1D enhances the prediction of CVD and major adverse cardiovascular events (MACE).

RESEARCH DESIGN AND METHODS

hs-cTnT and NT-proBNP were analyzed on the Roche Cobas E601 using the first available stored specimen (n = 581; mean age 29 years and diabetes duration 21 years). CVD was defined as CVD death, myocardial infarction, coronary revascularization, angina, ischemia, or stroke, and MACE as CVD death, myocardial infarction, or stroke.

RESULTS

Median hs-cTnT (5.0 ng/L; interquartile range <3.0, 10.0) was higher among men (P < 0.0001), whereas median NT-proBNP (22.0 ng/L; 7.0, 61.0) did not differ by sex. In Cox models, log hs-cTnT (hazard ratio [HR] 1.38, P = 0.0006) and log NT-proBNP (HR 1.24, P = 0.0001) independently predicted CVD during 21 years of follow-up. However, their addition to models, singly or together, did not significantly improve CVD prediction. Furthermore, a marginally significant sex interaction was observed (P = 0.06), indicating that the hs-cTnT prediction was limited to men. hs-cTnT and NT-proBNP also predicted MACE, although only NT-proBNP remained significant (HR 1.27, P = 0.0009) when the biomarkers were included in a model simultaneously. Nonetheless, their addition to multivariable models did not enhance MACE prediction.

CONCLUSIONS

Sex differences were observed in the concentration and predictive ability of hs-cTnT and NT-proBNP in T1D. Overall, their addition to traditional risk factor models increased the area under the curve for neither CVD nor MACE.

Frequency of Reduced Left Ventricular Contractile Efficiency and Discoordinated Myocardial Relaxation in Patients Aged 16 to 21 Years With Type 1 Diabetes Mellitus (from the Emerald Study)

Early-onset cardiomyopathy is a major concern for people with type 1 diabetes mellitus (DM). Studies examining myocardial deformation indices early in the disease process in people with have provided conflicting results. Accordingly, the objective was to examine left ventricular (LV) function in adolescents with type 1 DM using novel measures of cardiomyopathy, termed ventricular discoordination indices, including systolic stretch fraction (SSF), and our newly developed diastolic relaxation fraction (DRF). Adolescents with DM (n = 16) and healthy controls (n = 20) underwent cardiac MRI (CMR) tissue tracking analysis for standard volumetric and functional analysis. Segment-specific circumferential strain and strain rate indices were evaluated to calculate standard mechanical dyssynchrony and discoordination. SSF and DRF were calculated from strain rate data. There were no global or regional group differences between participants with DM and controls in standard LV strain mechanics. However, youth with DM had lower diastolic strain rate around the inferior septal and free wall region (all p <0.05) as well as higher SSF (p = 0.03) and DRF (p <0.001) compared with controls. None of the CMR indices correlated with HbA1c or diabetes duration. In conclusion, our results suggest that adolescents with DM have LV systolic and diastolic discoordination, providing early evidence of cardiomyopathy despite their young age. The presence of discoordination in the setting of normal LV size and function suggests that the proposed novel discoordination indices could serve as a more sensitive marker of cardiomyopathy than previously employed mechanical deformation indices.

Association between Circulating B-Type Natriuretic Peptide and Diabetic Peripheral Neuropathy: A Cross-Sectional Study of a Chinese Type 2 Diabetic Population

Cardiovascular disease which is associated with cardiac dysfunction, usually measured with circulating levels of B-type natriuretic peptide (BNP), has been associated with incidence and progression of diabetic peripheral neuropathy (DPN). The potential relationship of circulating physiological levels of BNP with DPN, however, has not been reported. Circulating levels of BNP were measured in 258 patients with type 2 diabetes mellitus (T2DM), and participants were divided into a DPN group (n = 61) and no DPN group (n = 197). The relationship between circulating physiological levels of BNP and DPN and other parameters was analyzed. Circulating levels of BNP were significantly elevated in T2DM patients with DPN compared to those without (P = 0.001). Circulating levels of BNP were significantly and positively associated with systolic blood pressure (P = 0.035), neutrophil-to-lymphocyte ratio (P = 0.007), creatinine (P = 0.030), vibration perception threshold values (P = 0.021), and the prevalence of diabetic foot ulceration (P = 0.039), peripheral arterial disease (P = 0.013), DPN (P = 0.032), and diabetic nephropathy (P = 0.020) and negatively with lymphocyte count (P = 0.003) and ankle-brachial index (P = 0.038), irrespective of age, sex, and body mass index. Moreover, circulating levels of BNP was an independent decisive factor for the presence of DPN after multivariate adjustment (odds ratio, 1.044; 95% confidence interval, 1.006-1.084; P = 0.024). Additionally, the higher quartiles of circulating BNP were related significantly to an increased risk of DPN compared to the lowest quartile (P = 0.003). Last but most importantly, the analysis of receiver operating characteristic curves revealed that the best cutoff value for circulating levels of BNP to predict DPN was 15.18 pg/mL (sensitivity 78.7% and specificity 48.2%). These findings suggest that high circulating physiological levels of BNP may be associated with the development of DPN and may be a potential biomarker for DPN in patients with T2DM.

Echocardiography improves prediction of major adverse cardiovascular events in a population with type 1 diabetes and without known heart disease: the Thousand & 1 Study

AIMS/HYPOTHESIS

Cardiovascular disease is the most common comorbidity in type 1 diabetes. However, current guidelines do not include routine assessment of myocardial function. We investigated whether echocardiography provides incremental prognostic information in individuals with type 1 diabetes without known heart disease.

METHODS

A prospective cohort of individuals with type 1 diabetes without known heart disease was recruited from the outpatient clinic. Follow-up was performed through Danish national registers. The association of echocardiography with major adverse cardiovascular events (MACE) and the incremental prognostic value when added to the clinical Steno T1D Risk Engine were examined.

RESULTS

A total of 1093 individuals were included: median (interquartile range) age 50.2 (39.2-60.3) years and HbA_1c 65 (56-74) mmol/mol; 53% men; and mean (SD) BMI 25.5 (3.9) kg/m² and diabetes duration 25.8 (14.6) years. During 7.5 years of follow-up, 145 (13.3%) experienced MACE. Echocardiography significantly and independently predicted MACE: left ventricular ejection fraction (LVEF) <45% (n = 18) vs ≥45% (n = 1075), HR (95% CI) 3.93 (1.91, 8.08), p < 0.001; impaired global longitudinal strain (GLS), 1.65 (1.17, 2.34) (n = 263), p = 0.005; diastolic mitral early velocity (E)/early diastolic tissue Doppler velocity (e') <8 (n = 723) vs E/e' 8-12 (n = 285), 1.59 (1.04, 2.42), p = 0.031; and E/e' <8 vs E/e' ≥12 (n = 85), 2.30 (1.33, 3.97), p = 0.003. In individuals with preserved LVEF (n = 1075), estimates for impaired GLS were 1.49 (1.04, 2.15), p = 0.032; E/e' <8 vs E/e' 8-12, 1.61 (1.04, 2.49), p = 0.033; and E/e' <8 vs E/e' ≥12, 2.49 (1.41, 4.37), p = 0.001. Adding echocardiographic variables to the Steno T1D Risk Engine significantly improved risk prediction: Harrell's C statistic, 0.791 (0.757, 0.824) vs 0.780 (0.746, 0.815), p = 0.027; and net reclassification index, 52%, p < 0.001.

CONCLUSIONS/INTERPRETATION

In individuals with type 1 diabetes without known heart disease, echocardiography significantly improves risk prediction over and above guideline-recommended clinical risk factors alone and could have a role in clinical care.

Assessment of left ventricular systolic and diastolic functions in severely malnourished children

Background

Malnourished children endure many changes in body composition and lose heart and skeletal muscle mass. Diastolic dysfunction is one of the major causes of heart failure with preserved ejection fraction.

Aim

To assess left ventricular systolic and diastolic functions in children with severe acute malnutrition using tissue Doppler imaging technique and to evaluate the effect of nutritional rehabilitation.

Patients and Methods

A follow-up case-control study conducted on 60 severely malnourished children (WHZ < -3SD) and 120 age and sex-matched healthy children as a control group. Tissue Doppler imaging (TDI) was done for all included malnourished children at admission and for control to measure left ventricular systolic and diastolic functions. Nutritional rehabilitation was done according to WHO protocol and tissue doppler was repeated after rehabilitation when (WHZ > -2SD) to detect any changes in systolic or diastolic functions.

Results

Systolic function was normal in malnourished children and control. Grade I diastolic dysfunction was detected in 40% and grade II in 30% of severely malnourished children in comparison to 100% normal diastolic function in control group. No correlations between diastolic dysfunction and either anthropometric measurements, electrolyte disturbances or Hb% in malnourished children before nutritional rehabilitation. Mortality from sepsis with associated ventricular dysfunction grade II documented in 3.3% of malnourished children. After nutritional rehabilitation diastolic function improved significantly as 65.6% of children attained normal diastolic function, 31% grade1 and 3.4% grade II. Positive correlations between diastolic function and WAZ, HAZ, WHZ and MUAC after rehabilitation.

Conclusion

Severe acute malnutrition affects diastolic function in children which is reversible in most of these cases with rehabilitation. TDI is an easy and practical method for detection and follow-up of ventricular function in malnourished children.

Left ventricular functions in pediatric patients with ten years or more type 1 diabetes mellitus: Conventional echocardiography, tissue Doppler, and two-dimensional speckle tracking study

BACKGROUND

Cardiac dysfunction is a complication of type 1 diabetes mellitus (T1DM) with primary concern in adults. However, studies have evaluated left ventricle (LV) myocardial changes in pediatrics but not the long-term effect of T1DM in such vulnerable age. Therefore, we assessed LV functions in pediatric patients with long-duration T1DM using different echocardiographic modalities.

METHODS

Between July 2015 and March 2016, 48 T1DM patients were prospectively compared to 35 healthy controls. Pediatric patients with T1DM for 10 years or more were included in the study. Patients were subjected to history taking, clinical examination, glycated hemoglobin (HbA1c), and microalbuminuria measurements. Moreover, conventional echocardiography, tissue Doppler, and 2D speckle tracking were performed to analyze LV functions.

RESULTS

Mean age of patients was 15.5 ± 2 years, and mean T1DM duration was 11.7 ± 1.8 years. LV dimensions, EF and FS, and mass index did not statistically differ between groups, but E/E' ratio was significantly higher in the diabetic group. Global longitudinal strain (GLS) and global circumferential strain (GCS) were significantly lower in diabetic patients compared with controls (P = 0.038; P = 0.001, respectively). Mean HbA1c was found to be a significant predictor of decreased GLS in the diabetic population (95% CI, 0.096-0.244; P = 0.001) but not predicting GCS. Microalbuminuria had no significance in predicting strain.

CONCLUSIONS

Despite the long-duration of affection with T1DM during childhood in our patients, alterations on LV myocardial function could not be detected either clinically or by conventional echocardiography. Tissue Doppler and speckle tracking could be used in the follow up of myocardial status in pediatric diabetic patients.

Impairment of left and right ventricular longitudinal strain in asymptomatic children with type 1 diabetes

Aim

The relationship between type 1 diabetes (T1DM) and cardiac function in children is not well established. The purpose of this study was to investigate whether children and adolescents with T1DM present early asymptomatic abnormalities of left ventricular (LV) and right ventricular (RV) function. In addition, we evaluated the relationship of any such abnormalities with glycemic control and diabetes duration.

Methods

This was a prospective study. Standard echocardiography, tissue Doppler imaging, and two-dimensional strain analysis were performed prospectively in 52 children with T1DM. The results were compared with those from 52 healthy children matched for age and sex.

Results

There were no significant differences between the two groups in LV ejection fraction or RV systolic function. There was a difference between the two study groups in transtricuspid flow: the E-wave and A-wave velocities were significantly higher in the diabetic group. Left ventricular global longitudinal strain (LV GLS) was significantly lower in children with T1DM (−20.01 ± 1.86% vs. −22.99 ± 0.98%, respectively; P < .001), as was RV free-wall longitudinal strain (RV FWLS) (−29.13 ± 1.85% vs. −30.22 ± 1.53%, respectively; P = .002). LV GLS was correlated with diabetes duration (r = 0.444, P < .001) and glycated hemoglobin (HbA1c) (r = 0.683, P < .001); however, no correlation was found between RV FWLS and HbA1c or diabetes duration.

Conclusions

Our findings suggest that LV GLS and RV FWLS are impaired in children with T1DM and that the decrease in LV GLS is correlated with diabetes duration and HbA1c levels.

Cardiac repolarization and depolarization in people with Type 1 diabetes with normal ejection fraction and without known heart disease: a case-control study

AIMS

To investigate depolarization and repolarization durations in people with Type 1 diabetes, including the relationship to age.

METHODS

855 persons with Type 1 diabetes without known heart disease were included and matched with 1710 participants from a general population study. Clinical examinations, questionnaires and biochemistry were assessed. A 10-second 12-lead ECG was performed and analysed digitally.

RESULTS

QT_c was longer in people with Type 1 diabetes compared to controls (414±16 vs. 411±19 ms, P <0.001), and particularly so in young people with Type 1 diabetes. The fully adjusted increase was 13.8 ms (95% confidence interval (CI): 8.6-19.0 ms, P <0.001) at age 20 years and 3.4 ms (CI: 1.5-5.3 ms, P<0.001) at age 40 years. The rate-corrected QRS_c was increased in people with Type 1 diabetes (97±11 vs. 95±11 ms, P <0.001) and was age-independent (P =0.5). JT_c was increased in the young people with Type 1 diabetes (10.7 ms (CI: 5.4-16.0 ms, P <0.001) at age 20 years), but not in older people with Type 1 diabetes (interaction age-diabetes, P <0.01).

CONCLUSIONS

For people with Type 1 diabetes, cardiac depolarization is increased at all ages, whereas repolarization is increased only relatively in young people with Type 1 diabetes. Hence, young people with Type 1 diabetes may be more prone to ventricular arrhythmias. The findings contribute to the understanding of sudden cardiac death in young people with Type 1 diabetes.

Three-dimensional speckle tracking echocardiography: Is it the magic wand in the diagnosis of subclinical myocardial dysfunction in children with type 1 diabetes mellitus?

OBJECTIVES

To revaluate the role of three-dimensional speckle tracking echocardiography (3D-STE) in the evaluation of subclinical myocardial dysfunction in asymptomatic children with type 1 diabetes mellitus (DM).

PATIENTS AND METHODS

Fifty asymptomatic children with type 1 DM were included as a patient group. Fifty healthy children of matched age, sex, and weight served as a control group. Laboratory investigations in the form of complete blood count (CBC), liver function test, renal function test, complete blood lipid profile, glycosylated hemoglobin (HbA1c), fasting and 2 hours postprandial (PP) glucose levels, and cardiac troponin I (cTnT I) were drawn. Complete echocardiographic evaluation of the left ventricular (LV) function was performed in the form of conventional echo, 2D strain, tissue Doppler imaging (TDI), and 3D- STE.

RESULTS

cTnT I levels were significantly higher in the patient group than the control group, and this increase was significantly correlated with Hb A1c. Conventional echocardiography showed normal systolic and diastolic function of the LV. Diastolic (by TDI) as well as systolic functions of LV (by 4D LV quantification tool) were found to be significantly lower in patient group than control group. 3D-STE examination showed that there was a significant decrease in all component of strain in patient group than control group and that decrease correlated well with 4D LV EF but did not correlate with the duration of DM. There was a significant negative correlation between longitudinal strain and the control of DM.

CONCLUSION

3D-STE is a good tool for prediction of early cardiac dysfunction in asymptomatic children with type 1 DM.

Asymmetric dimethylarginine levels and diabetes duration: Relationship with measures of subclinical atherosclerosis and cardiac function in children and adolescents with Type 1 diabetes

AIMS

We aimed to evaluate asymmetric dimethylarginine levels in young patients with Type 1 diabetes mellitus according to diabetes duration and to examine the relationship between these levels and measures of atherosclerosis and myocardial function.

MATERIALS AND METHODS

In total, 83 patients (8.5-22 years) with Type 1 diabetes mellitus were stratified by diabetes duration: 12-60 months (Group 1, n = 27), >60-120 months (Group 2, n = 29) and >120 months (Group 3, n = 27). Asymmetric dimethylarginine levels were assessed. Carotid intima-media thickness was measured. Myocardial function was assessed by M-mode, conventional Doppler and tissue Doppler echocardiography.

RESULTS

Asymmetric dimethylarginine level was significantly higher in Group 1, while carotid intima-media thickness was significantly greater in Group 3 ( p < 0.05). Tissue Doppler echocardiography showed the ratio of peak early to peak late diastolic myocardial annular velocity decreased significantly in Groups 2 and 3 with a negative correlation with duration (r: -0.310, p = 0.004) and HBA1c levels (r = -0.391, p < 0.001). Myocardial performance index in all groups and isovolumic relaxation time in Group 3 increased significantly. Asymmetric dimethylarginine levels were negatively correlated with carotid intima-media thickness and isovolumic relaxation time ( p < 0.05).

CONCLUSION

In contrast to adult diabetics, asymmetric dimethylarginine concentration decreases as diabetes duration increases in young Type 1 diabetic patients and is associated with worsening measures of cardiovascular risk and poorer diastolic function.

Subclinical left ventricular systolic and diastolic dysfunction in type 1 diabetic children and adolescents with good metabolic control

OBJECTIVE

Cardiac dysfunction is a well-known consequence of diabetes mellitus. This study was designed to assess whether type 1 diabetic children and adolescents with good metabolic control have early echocardiographic signs of subclinical left ventricular dysfunction and whether diabetes duration has any influence, using conventional and nonconventional echocardiographic tools.

METHODS

A total of 100 patients with type 1 diabetes mellitus and 80 gender- and age-matched healthy controls were included. The cases underwent standard conventional transthoracic echocardiography, tissue Doppler imaging, and two-dimensional speckle tracking echocardiography. None of the diabetic patients had signs of renal, retinal, or neurological complications of the disease, and all were good metabolic control (mean HbA_1c <7.5%).

RESULTS

There was no difference among groups in relation to age, sex, body mass index, and blood pressure. Conventional echocardiographic parameters were similar between diabetic and nondiabetic subjects except increased mitral valve peak A-wave and significantly lower mitral E/A ratio in diabetics. Diabetic patients had more advanced diastolic dysfunction with TDI analysis. In the diabetic group, left ventricular global longitudinal, circumferential, and radial strain and strain rate were significantly lower compared with the controls. There was a positive correlation between diabetes duration and cardiac dysfunction.

CONCLUSION

The results of this study showed that the diabetic children and adolescents with good metabolic control had diastolic dysfunction when assessed with either conventional or tissue Doppler echocardiography. Also diabetic patients had subclinical LV systolic dysfunction with a normal LVEF which can be detected with 2D speckle tracking echocardiography.

Advanced glycation end products in children with type 1 diabetes and early reduced diastolic heart function

BACKGROUND

Reduced diastolic function is an early sign of diabetes cardiomyopathy in adults and is associated with elevated levels of HbA1c and advanced glycation end products (AGEs).

OBJECTIVE

To assess the associations between early reduced diastolic function and elevated levels of HbA1c and AGEs in children and adolescents with type 1 diabetes (T1D).

METHODS

One hundred fourty six T1D patients (age 8-18 years) without known diabetic complications were examined with tissue Doppler imaging and stratified into two groups according to diastolic function. A clinical examination and ultrasound of the common carotid arteries were performed. Methylglyoxal-derived hydroimidazolone-1 (MG-H1) was measured by immunoassay.

RESULTS

At inclusion, 36 (25%) participants were stratified into a low diastolic function group (E'/A'-ratio < 2.0). Compared to the rest of the T1D children, these participants had higher body mass index (BMI), 22.8 (SD = 4.0) vs. 20.1 (SD = 3.4) kg/m², p < 0.001, higher systolic blood pressure 104.2 (SD = 8.7) vs. 99.7 (SD = 9.3) mmHg, p = 0.010, and higher diastolic blood pressure, 63.6 (SD = 8.3) vs. 59.9 (SD = 7.9) mmHg, p = 0.016. The distensibility coefficient was lower, 0.035 (SD = 0.010) vs. 0.042 (SD = 0.02) kPa^-1, p = 0.013, Young's modulus higher, 429 (SD = 106) vs. 365 (SD = 143), p = 0.009, and MG-H1 higher, 163.9 (SD = 39.2) vs. 150.3 (SD = 33.4) U/ml, p = 0.046. There was no difference in carotid intima-media thickness between the groups. There were no associations between reduced diastolic function and years from diagnosis, HBA1c, mean HBA1c, CRP or calculated glycemic burden. Logistic regression analysis showed that BMI was an independent risk factor for E'/A'-ratio as well as a non-significant, but relatively large effect size for MG-H1, indicating a possible role for AGEs.

CONCLUSIONS

Early signs of reduced diastolic function in children and adolescents with T1D had higher BMI, but not higher HbA1c. They also had elevated serum levels of the advanced glycation end product MG-H1, higher blood pressure and increased stiffness of the common carotid artery, but these associations did not reach statistical significance when tested in a logistic regression model.

Decreased regional left ventricular myocardial strain in type 1 diabetic children: a first sign of diabetic cardiomyopathy?

BACKGROUND AND OBJECTIVES

Type 1 diabetes is a major cardiovascular risk factor associated with an excess of mortality in young adults due to premature cardiovascular events, which includes heart failure. The relation between type 1 diabetes and cardiac structure and function in children was poorly documented. Our study investigates (1) whether type 1 diabetic children have echocardiographic signs of subclinical cardiac dysfunction assessed by tissue Doppler strain and (2) whether state of metabolic control and diabetes duration have any influence on the cardiac event.

METHODS

Standard echocardiography and tissue Doppler imaging were prospectively performed in type 1 diabetic children. Left ventricular dimensions, standard indices of systolic and diastolic function, and septal longitudinal strain were investigated.

RESULTS

Thirty consecutive asymptomatic diabetic children (age: 12.4 [5-17] years; males: 53%) were compared to 30 age and sex-matched healthy control subjects. Left ventricular mass index and diastolic septal thickness were significantly increased in diabetic children. There was no difference between two groups as regards the left ventricular ejection fraction and conventional mitral Doppler parameters (E, A, Ea). The global longitudinal systolic strain and strain rate were found to be decreased in children with diabetes. The global longitudinal early diastolic strain rate (Esr) was negatively correlated with metabolic control. Longitudinal strain was not correlated with diabetes duration.

CONCLUSION

Children with Type 1 diabetes had subclinical alterations in left ventricular size and longitudinal myocardial deformation.

Early reduced myocardial diastolic function in children and adolescents with type 1 diabetes mellitus a population-based study

BACKGROUND

Reduced diastolic myocardial function is an early sign of diabetic cardiomyopathy. The aim of this study was to test the hypothesis that children and adolescents with type 1 diabetes mellitus (T1D), but without other known complications, have early reduced diastolic myocardial function diagnosed with echocardiographic color tissue Doppler imaging (cTDI).

METHODS

cTDI examination was carried out in 173 T1D patients and 62 age-matched controls. The T1D-patients were 8-18 years old with (mean (SD)) diabetes duration of 5.6 (3.4) years and HbA1c of 8.4 (1.3). All were treated with either insulin pumps or 4-6 daily insulin injections. cTDI early (E') and late (A') peak diastolic velocities and systolic peak velocity were measured from the lateral, septal, anterior and posterior mitral annulus and from the lateral tricuspidal annulus.

RESULTS

Myocardial diastolic function was reduced in the T1D-patients with higher peak A'-velocity and lower E'/A'-ratio in all registrations. Overall mean (SD) mitral E'/A'-ratio was 2.3 (0.5) in T1D and 2.7 (0.6) in the controls (p < 0001). The overall mitral E'/A'-ratio was negative associated with blood pressure (BP) and body mass index (BMI). Stratifying all participants into three groups according to BMI (<25, 25-75, >75 centile, respectively), the T1D had lower E'/A'-values in all stratified groups, except for in the highest BMI-group where both T1D and controls had the lowest E'/A'-ratio. Systolic function did not differ in any of the measurements. There were no associations with sex, diabetes duration, carotid artery intima-media-thickness, vessel elasticity or HbA1c.

CONCLUSION

Diabetic children and adolescents using modern intensive insulin treatment had echocardiographic signs of reduced diastolic myocardial function despite short duration of disease. The reduced function was associated with higher BP and higher BMI.

Subclinical Left Ventricular Longitudinal and Radial Systolic Dysfunction in Children and Adolescents with Type 1 Diabetes Mellitus

INTRODUCTION

There are few studies of subclinical systolic dysfunctions in children and adolescents with type 1 diabetes mellitus (DM), and so the available data are limited. The aim of this study was to determine early echocardiographic signs of LV systolic dysfunction in children and adolescents with type 1 DM using two-dimensional speckle tracking echocardiography (2DSTE).

MATERIAL AND METHODS

The study included 84 children and adolescents with type 1 DM and 32 sex-, age-, and body mass index-matched healthy subjects. The LV functions were assessed using conventional echocardiography, tissue Doppler imaging, and 2DSTE.

RESULTS

The results showed LV diastolic dysfunction as reflected by significantly increased A-wave velocity, decreased E/A ratio, and increased early filling deceleration time in the patients with diabetes (P = 0.02, P = 0.029, and P = 0.04; respectively). Compared with the control group, patients with diabetes showed significantly lower values for longitudinal systolic strain and strain rate in most segments of the LV; for radial strain values of the LV; for lateral circumferential strain and posterior and anterolateral circumferential strain rate of the LV; and for global longitudinal and radial strain of the LV. Global longitudinal and radial strain values of the LV were significantly lower among patients with poor glycemic control than in the control group.

CONCLUSION

In addition to diastolic dysfunction, LV longitudinal and radial function was found to be impaired in asymptomatic children and adolescents with type 1 DM who have normal LV ejection fraction by 2DSTE. Glycemic control may be the main risk factor for alteration of myocardial function.

Cardiac antibody production to self-antigens in children and adolescents during and following the correction of severe diabetic ketoacidosis

Diabetic cardiomyopathy (DC) is an independent phenotype of diabetic cardiovascular disease. The understanding of the pathogenesis of DC in young patients with type 1 diabetes (T1D) is limited. The cardiac insults of diabetic ketoacidosis (DKA) and progression of DC could include development of antibodies (Abs) to cardiac self-antigens (SAgs) such as: myosin (M), vimentin (V) and k-alpha 1 tubulin (Kα1T). The goal of this study is to determine if the insults of severe DKA and its inflammatory cascade are associated with immune responses to SAgs. Development of Abs to the SAgs were determined by an ELISA using sera collected at three time points in relation to severe DKA (pH < 7.2). Results demonstrate significant differences between the development of Abs to VIM and a previously reported diastolic abnormality (DA) during DKA and its treatment and a NDA group at 2-3 months post DKA (p = 0.0452). A significant association is present between T1D duration (<3 years) and Abs to Kα1T (p = 0.0134). Further, Abs to MYO and VIM are associated with inflammatory cytokines. We propose that severe DKA initiates the synthesis of Abs to cardiac SAgs that are involved in the early immunopathogenesis of DC in young patients with T1D.

Can ambulatory blood pressure monitoring detect early diastolic dysfunction in children with type 1 diabetes mellitus: correlations with B-type natriuretic peptide and tissue Doppler findings

AIM

To evaluate the relationship between 24-h blood pressure (BP) measurements and diastolic heart function evaluated by Doppler tissue imaging and B-type natriuretic peptide (BNP) levels in children with type 1 diabetes mellitus (DM).

PATIENTS AND METHODS

A total of 32 diabetic and 18 healthy children were enrolled. Spectral Doppler analysis and tissue Doppler measurements were performed by conventional echocardiography. The 24-h ambulatory BP and serum BNP levels were measured.

RESULTS

Analysis of ambulatory blood pressure monitoring (ABPM) recordings showed that median daytime diastolic BP load were significantly higher in diabetic patients compared to controls [12.35 (4.23-27.23) vs. 2.5 (0-8.7), p = 0.007]. Patients with elevated daytime systolic and diastolic BP loads had significantly higher BNP values compared to patients with normal BP load (31.4 ± 24.36 vs. 11.84 ± 11.25 pg/mL, p = 0.03 and 23.21 ± 15.12 vs. 12.12 ± 14.65 pg/mL, p = 0.03, respectively). Isovolemic contraction time (47.43 ± 7.84 vs. 42.27 ± 7.47, p = 0.045), isovolemic relaxation time (68.84 ± 10.43 vs. 58.77 ± 10.02, p = 0.02), and myocardial performance index (0.45 ± 0.10 vs. 0.37 ± 0.09, p = 0.02) as determined by tissue Doppler echocardiography were significantly high in diabetic patients compared to that of control cases. Ratio of mitral peak early diastolic flow velocity (E) to peak early diastolic myocardial velocities by tissue Doppler echocardiography (E') was also higher in patients with elevated daytime systolic BP load (E/E', 6.71 ± 1.97 vs. 4.91 ± 1.02, p = 0.04).

CONCLUSION

Elevated BP loads detected by 24-h ambulatory BP measurements in children with type 1 diabetes are associated with increased BNP levels and abnormal tissue Doppler echocardiography indices, indicating early stage cardiac dysfunction.

Left and right ventricular systolic function impairment in type 1 diabetic young adults assessed by 2D speckle tracking echocardiography

AIMS

Subclinical left ventricular (LV) and right ventricular (RV) systolic dysfunction has been proved in type 2 diabetes mellitus (DM). There is lack of uniform data on systolic myocardial function in type 1 DM. The aim of this study was to evaluate LV and RV function with 2D speckle tracking echocardiography (2D STE) in adult type 1 diabetic patients.

METHODS AND RESULTS

Totally, 50 patients with type 1 DM and 50 control subjects in the same range of age were prospectively evaluated. The 2D STE assessment of LV longitudinal, radial, circumferential strain and RV free-wall longitudinal strain was performed. In diabetic group, left ventricular global longitudinal strain (LVGLS), left ventricular global circumferential strain (LVGCS), left ventricular radial strain at basal level (LVRS-basal), and right ventricular free-wall global longitudinal strain (RVGLS) were significantly lower compared with the controls: LVGLS (-20.3 ± 2.0% vs. -22.2 ± 1.8%, P < 0.001), LVGCS (-21.1 ± 2.5% vs. -22.2 ± 2.4%, P < 0.05), LVRS-basal (50.5% ± 11.5 vs. 57.1% ±17.0, P < 0.05), and RVGLS (-30.1% ± 3.5 vs. -32.7% ± 3.9, P < 0.01). Multivariable logistic regression analysis showed that the only independent predictor of reduced LVGLS was low-density lipoprotein cholesterol [odds ratio 3.65 (95% confidence interval: 1.27-10.5), P = 0.014].

CONCLUSION

Type 1 DM is associated with subclinical LV systolic dysfunction and worse RV systolic function, which can be detected with 2D STE.

Osteopontin is a strong predictor of incipient diabetic nephropathy, cardiovascular disease, and all-cause mortality in patients with type 1 diabetes

OBJECTIVE

Osteopontin (OPN) is a multifunctional protein suggested to be a player in the arterial disease of patients with type 2 diabetes. However, its role for complications in patients with type 1 diabetes (T1D) is unknown. We therefore investigated the associations between OPN and diabetic vascular complications and all-cause mortality in patients with T1D.

RESEARCH DESIGN AND METHODS

Serum OPN was measured in 2,145 adults with T1D without end-stage renal disease (ESRD; dialysis or transplantation) as part of the Finnish Diabetic Nephropathy (FinnDiane) Study. Data on renal status, cardiovascular disease (CVD), and all-cause mortality during follow-up were verified from medical files, hospital discharge registries, and the Finnish National Death Registry, respectively. The median follow-up time was 10.5 (interquartile range 8.9-11.8) years.

RESULTS

Serum OPN was higher at baseline in patients who developed incident microalbuminuria (16.0 ± 0.9 vs. 14.1 ± 0.2 µg/L; P = 0.04), progressed to ESRD (28.3 ± 1.7 vs. 15.4 ± 0.2 µg/L; P < 0.001), suffered an incident CVD event (20.2 ± 1.2 vs. 15.5 ± 0.2 µg/L; P < 0.001), or died (23.3 ± 1.4 vs. 15.8 ± 0.2 µg/L; P < 0.001) during follow-up. In multivariate Cox regression analysis, OPN was independently associated with the development of incident microalbuminuria, an incident CVD event, and death, after adjustments for associated risk factors. Even after calculating reclassification indexes, OPN was predictive of CVD and all-cause mortality beyond the Framingham risk score covariates and hs-CRP.

CONCLUSIONS

Serum OPN is a strong predictor of incipient diabetic nephropathy, a first-ever CVD event, and all-cause mortality in patients with T1D. Serum OPN may be of clinical significance for the risk prediction of CVD events in patients with T1D.

Lipid profile and correlation to cardiac risk factors and cardiovascular function in type 1 adolescent diabetics from a developing country

Objective. The adverse role of dyslipidemia in predicting cardiovascular outcomes has not been elucidated extensively among type 1 diabetics in the literature. Methods. We assessed dyslipidemia and its correlation to other cardiac risk factors in adolescents with type 1 diabetes. Total thirty type 1 adolescent diabetics were evaluated for their metabolic profile, including serum lipids and echocardiography was performed. Results. The average age of the cohort was 14.3 ± 3.09 yr with disease duration of 5.35 ± 2.94 yr. The mean HbA1C was 8.01%. The mean serum cholesterol, LDL, HDL, and triglyceride were normal. Serum cholesterol was high in patients with longer disease duration (P = 0.011, r = 0.41), high systolic blood pressure (P = 0.04, r = 0.32), and elevated HbA1C > 8% (P = 0.038, r = 0.33). Higher lipid values were associated with poorer carotid artery distensibility (P > 0.05) and higher carotid artery intimomedial thickness (cIMT) (P < 0.05 for cholesterol and LDL). Hyperglycemia adversely affected ejection fractions, though serum lipids did not show any significant effect on left ventricular parameters. Conclusions. Dyslipidemia and hyperglycemia can serve as biomarkers for cardiovascular dysfunction in at-risk adolescents with type 1 diabetes. Carotid artery parameters are adjunctive tools which may be affected early in the course of macrovascular disease.

Longitudinal left ventricular strain impairment in type 1 diabetes children and adolescents: a 2D speckle strain imaging study

AIM

Type 1 diabetes (T1D) involves complex metabolic disturbances in cardiomyocytes leading to morphological and functional abnormalities of the myocardium. The relationship between T1D and cardiac structure and function in children is not well established. Our study investigated whether T1D is associated with early subclinical myocardial disturbances in children and adolescents, and whether the state of metabolic control and diabetes duration are influential factors.

METHODS

Standard echocardiography, tissue Doppler imaging (TDI) and two-dimensional (2D) strain imaging were prospectively performed in 100 T1D children (age: 11.3 ± 3.6 years, 52 boys) and compared with 79 controls.

RESULTS

The diabetic and control children were comparable with respect to age, gender, heart rate and blood pressure. There were no significant differences between the two groups in left ventricular (LV) ejection fraction, LV remodelling and TDI parameters. Conventional mitral Doppler demonstrated significantly fewer diastolic filling abnormalities with an early filling wave in the diabetes group. Global longitudinal strain (GLS) was also significantly lower in the T1D children, while circumferential strain and radial strain did not differ. GLS correlated with HbA1c (r=0.52; P<0.01), but there was no correlation with diabetes duration.

CONCLUSION

Our results suggest that LV longitudinal myocardial deformation is decreased in young patients with T1D, and glycaemic control may be the main risk factor for these changes. Further follow-up is now necessary to precisely determine the clinical significance of these myocardial changes detected by 2D strain imaging in T1D children.

Prevalence of systolic and diastolic dysfunction in patients with type 1 diabetes without known heart disease: the Thousand & 1 Study

AIMS/HYPOTHESIS

Heart failure is one of the leading causes of mortality in type 1 diabetes. Early identification is vitally important. We sought to determine the prevalence and clinical characteristics associated with subclinical impaired systolic and diastolic function in type 1 diabetes patients without known heart disease.

METHODS

In this cross-sectional examination of 1,093 type 1 diabetes patients without known heart disease, randomly selected from the Steno Diabetes Center, complete clinical and echocardiographic examinations were performed and analysed in uni- and multivariable regression models.

RESULTS

The mean (SD) age was 49.6 (15) years, 53% of participants were men, and the mean duration of diabetes was 25.5 (15) years. Overall, 15.5% (n = 169) of participants had grossly abnormal systolic or diastolic function, including 1.7% with left ventricular ejection fraction (LVEF) < 45% and 14.4% with evidence of long-standing diastolic dysfunction. In univariable models, clinical characteristics associated with abnormal myocardial function were: age (per 10 years), OR (95% CI) 2.1 (1.8, 2.4); diabetes duration (per 10 years), 1.7 (1.4, 1.9); systolic BP ≥ 140 mmHg, 2.7 (1.9, 3.8); diastolic BP ≥ 90 mmHg, 1.8 (1.0, 3.1); estimated (e)GFR < 60 ml min(-1) 1.73 m(-2), 3.8 (2.5, 5.9); microalbuminuria, 2.0 (1.3, 3.0); macroalbuminuria, 5.9 (3.8, 9.3); proliferative retinopathy, 3.6 (2.3, 5.8); blindness, 10.1 (3.2, 31.6); and peripheral neuropathy, 3.8 (2.7, 5.3). In multivariable models only age (2.1 [1.7, 2.5]), female sex, (1.9 [1.2, 2.8]) and macroalbuminuria (5.2 [2.9, 10.3]) remained significantly associated with subclinical grossly abnormal myocardial function.

CONCLUSIONS/INTERPRETATION

Subclinical myocardial dysfunction is a common finding in type 1 diabetes patients without known heart disease. Type 1 diabetes patients with albuminuria are at greatly increased risk of having subclinical abnormal myocardial function compared with patients without albuminuria. Echocardiography may be particularly warranted in patients with albuminuria.

Prevalence, predictors and evolution of echocardiographically defined cardiac abnormalities in adults with type 1 diabetes: an observational cohort study

AIMS/HYPOTHESIS

The aims of this observational study were to determine the prevalence and predictors of an abnormal echocardiogram in adults with type 1 diabetes, and to assess the evolution of changes in a subset of subjects.

METHODS

Cardiac function and structure were prospectively investigated by comprehensive transthoracic echocardiographic techniques in asymptomatic adults with type 1 diabetes seen in the ambulatory care setting.

RESULTS

We recruited 136 subjects (mean age 39 years, SD 14 years) with a median diabetes duration of 21 years [25(th), 75(th) interquartile range; 11, 29]. An abnormal echocardiogram was present in 29% of subjects; diastolic dysfunction in 69%, left ventricular hypertrophy in 38% and systolic dysfunction in 10%. The independent predictors of an abnormal echocardiogram were age, with a 9-fold increase in those ≥40 years (OR 9.40 [95% CI 2.68-33.04], P <0.0001), and increased body mass index (BMI), with a 17% increase in risk (P=0.04). A second echocardiogram was available in 65 subjects (3.8±1.7 years later). The results showed that one in five with a normal first study had developed an abnormal second study, mainly diastolic dysfunction, with age being the only independent predictor of progression (P=0.006).

CONCLUSIONS/INTERPRETATION

Subclinical echocardiographic abnormalities are common in asymptomatic type 1 diabetes adults, and changes are progressive. The addition of an echocardiogram to complication surveillance programs in those with type 1 diabetes aged ≥40 years may represent a cost-effective way to screen for, and aggressively treat, occult cardiac disease.

Plasma glucose levels and left ventricular diastolic function in nondiabetic hypertensive patients

BACKGROUND

Changes in left ventricular (LV) diastolic filling anticipate diastolic heart failure and are frequently detected in patients with hypertension or diabetes. We tested the hypothesis that increased fasting and postload glucose levels are associated with diastolic dysfunction as assessed by tissue Doppler imaging (TDI) in hypertensive patients.

METHODS

In 104 untreated, nondiabetic, hypertensive patients free of cardiovascular complications, we measured glucose and insulin at fast and after an oral glucose load, calculated the Homeostatic Model Assessment (HOMA) index, and performed electrocardiogram (ECG), conventional echocardiography, and TDI.

RESULTS

Thirty-one patients who had impaired fasting glucose/impaired glucose tolerance had more frequent LV strain at ECG and worse TDI markers of diastolic function than patients with normal plasma glucose but no differences in variables LV mass, LV geometry, systolic function, and early-/late-wave transmitral diastolic velocity. TDI detected diastolic dysfunction in 46 patients who were older and had greater body mass index, blood pressure, fasting and postload glucose, insulin, HOMA index, LV mass, and left atrial diameter than patients with preserved diastolic function. Variables of diastolic function measured at TDI were significantly related with age, body mass index, LV mass, and fasting and postload plasma glucose. Stepwise regression analysis showed that the relationship of markers of diastolic dysfunction with both fasting and postload glucose levels was independent of possible confounders.

CONCLUSIONS

Initially abnormal fasting and postload glucose levels are associated with more prominent diastolic impairment in uncomplicated hypertensive patients, suggesting that hyperglycemia might increase the risk of diastolic heart failure even in the absence of diabetes.

Pediatric cardiomyopathies: causes, epidemiology, clinical course, preventive strategies and therapies

Pediatric cardiomyopathies, which are rare but serious disorders of the muscles of the heart, affect at least one in every 100,000 children in the USA. Approximately 40% of children with symptomatic cardiomyopathy undergo heart transplantation or die from cardiac complications within 2 years. However, a significant number of children suffering from cardiomyopathy are surviving into adulthood, making it an important chronic illness for both pediatric and adult clinicians to understand. The natural history, risk factors, prevalence and incidence of this pediatric condition were not fully understood before the 1990s. Questions regarding optimal diagnostic, prognostic and treatment methods remain. Children require long-term follow-up into adulthood in order to identify the factors associated with best clinical practice including diagnostic approaches, as well as optimal treatment approaches. In this article, we comprehensively review current research on various presentations of this disease, along with current knowledge about their causes, treatments and clinical outcomes.

Increased systemic Th17 cytokines are associated with diastolic dysfunction in children and adolescents with diabetic ketoacidosis

Diastolic dysfunction suggestive of diabetic cardiomyopathy is established in children with T1DM, but its pathogenesis is not well understood. We studied the relationships of systemic inflammatory cytokines/chemokines and cardiac function in 17 children with T1DM during and after correction of diabetic ketoacidosis (DKA). Twenty seven of the 39 measured cytokines/chemokines were elevated at 6-12 hours into treatment of DKA compared to values after DKA resolution. Eight patients displayed at least one parameter of diastolic abnormality (DA) during acute DKA. Significant associations were present between nine of the cytokine/chemokine levels and the DA over time. Interestingly, four of these nine interactive cytokines (GM-CSF, G-CSF, IL-12p40, IL-17) are associated with a Th17 mediated cell response. Both the DA and CCL7 and IL-12p40, had independent associations with African American patients. Thus, we report occurrence of a systemic inflammatory response and the presence of cardiac diastolic dysfunction in a subset of young T1DM patients during acute DKA.

Impaired diastolic function and elevated Nt-proBNP levels in type 1 diabetic patients without overt cardiovascular disease

Diabetic cardiomyopathy is an important complication of type 1 diabetes mellitus. Diastolic heart failure is an early manifestation of diabetic cardiac disease. Nt-proBNP is a valuable marker of ventricular dysfunction. The aim of this study was to determine Nt-proBNP concentrations in type 1 diabetic patients and determine their relationship with ventricular diastolic dysfunction (DD) and carotid artery intima media thickness (CIMT) measurements. Sixty-seven type 1 diabetic patients (30.2 ± 8.0 years; W/M: 24/43) without known cardiovascular disease and 48 healthy controls (30.5 ± 6.4 years; W/M: 19/29) were recruited. Nt-proBNP levels were measured. Conventional and tissue Doppler echocardiography were used to evaluate left ventricular diastolic function and CIMT. Nt-proBNP in diabetic patients was significantly higher than in controls (38 ± 34.8 vs. 15.1 ± 12.7 pg/ml) (P = 0.004). Ea level was higher (12.3 ± 3 vs. 10.3 ± 4 cm/s, P = 0.003) and E/Ea ratio was lower in patients (6.6 ± 2.5 vs. 9.7 ± 5.9, P = 0.001) compared with controls. Ratio of DD was higher in patients than controls (11.1 vs. 2.1%, P = 0.01). CIMT measurements in diabetic patients were higher than controls (0.54 ± 0.11 vs. 0.48 ± 0.05 mm, P = 0.02). Logistic regression revealed age and HbA1c to be independently associated with the presence of DD. Nt-proBNP levels are elevated in type 1 diabetic patients without overt cardiovascular disease and the presence of DD is increased in diabetic patients in comparison with controls. Nt-proBNP levels do not seem to be related to the presence of DD and subclinical atherosclerosis in this group of patients.

Cardiovascular disease in children and adolescents with diabetes: where are we, and where are we going?

The increasing prevalence of type 1 and type 2 diabetes mellitus combined with advancement in early detection of cardiovascular disease (CVD) has placed CVD as a significant concern for preventative pediatric medicine. The public health burden of type 2 diabetes is predicted to parallel increasing obesity in children with a projected increase of early CVD in adulthood. In this article, we review practice guidelines for cardiovascular health in children and adolescents with diabetes and data on which they are based. We then focus on imaging modalities that are promising tools to expand our understanding of the cardiovascular risk imposed on youths with diabetes.

[Assessment of diastolic function in children and adolescents with type 1 diabetes mellitus - are there early signs of diabetic cardiomyopathy?]

OBJECTIVES

To evaluate diastolic function (DF) of children and adolescents with type 1 diabetes mellitus (DM1).

SUBJECTS AND METHODS

Cross-sectional study of 67 otherwise healthy diabetic patients, and a control group (n = 84) in regard to age, sex, body mass index (BMI), Dopplere-chocardiography, and ECG for both groups; and disease duration, HbA1C, microalbuminuria, and serum lipids for DM 1 patients.

RESULTS

Diastolic alterations [(A and E mitral waves, E/A ratio, isovolumic relaxation time (IVRT) and E wave deceleration time (EWDT)] were found in diabetic patients, with higher prevalence among pubertal girls (13-17 years old). IVRT and EWDT correlated positively with BMI (p = 0.028). Chronological age and disease duration were predictive factors for mitral A wave (p = 0.004 and 0.033, respectively).

CONCLUSIONS

DF alterations were detected in the group of diabetic patients, with greater prevalence among pubertal girls; disease duration and age influenced parameters of DF.

Cardiovascular disease risk in young people with type 1 diabetes

Cardiovascular disease (CVD) is the most frequent cause of death in people with type 1 diabetes (T1D), despite modern advances in glycemic control and CVD risk factor modification. CVD risk identification is essential in this high-risk population, yet remains poorly understood. This review discusses the risk factors for CVD in young people with T1D, including hyperglycemia, traditional CVD risk factors (dyslipidemia, smoking, physical activity, hypertension), as well as novel risk factors such as insulin resistance, inflammation, and hypoglycemia. We present evidence that adverse changes in cardiovascular function, arterial compliance, and atherosclerosis are present even during adolescence in people with T1D, highlighting the need for earlier intervention. The methods for investigating cardiovascular risk are discussed and reviewed. Finally, we discuss the observational studies and clinical trials which have thus far attempted to elucidate the best targets for early intervention in order to reduce the burden of CVD in people with T1D.

Cardiovascular status of childhood cancer survivors exposed and unexposed to cardiotoxic therapy

PURPOSE

To determine whether cardiovascular abnormalities in childhood cancer survivors are restricted to patients exposed to cardiotoxic anthracyclines and cardiac irradiation and how risk factors for atherosclerotic disease and systemic inflammation contribute to global cardiovascular status.

METHODS

We assessed echocardiographic characteristics and atherosclerotic disease risk in 201 survivors of childhood cancer with and without exposure to cardiotoxic treatments at a median of 11 years after diagnosis (range, 3 to 32 years) and in 76 sibling controls.

RESULTS

The 156 exposed survivors had below normal left ventricular (LV) mass, wall thickness, contractility, and fractional shortening and above normal LV afterload. The 45 unexposed survivors also had below normal LV mass overall, and females had below normal LV wall thickness. Exposed and unexposed survivors, compared with siblings, had higher levels of N-terminal pro-brain natriuretic peptide (81.7 and 69.0 pg/mL, respectively, v 39.4 pg/mL), higher mean fasting serum levels of non-high-density lipoprotein cholesterol (126.5 and 121.1 mg/dL, respectively, v 109.8 mg/dL), higher insulin levels (10.4 and 10.5 μU/mL, respectively, v 8.2 μU/mL), and higher levels of high-sensitivity C-reactive protein (2.7 and 3.1 mg/L, respectively, v 0.9 mg/L; P < .001 for all comparisons). Age-adjusted, predicted-to-ideal 30-year risk of myocardial infarction, stroke, or coronary death was also higher for exposed and unexposed survivors compared with siblings (2.16 and 2.12, respectively, v 1.70; P < .01 for both comparisons).

CONCLUSION

Childhood cancer survivors not receiving cardiotoxic treatments nevertheless have cardiovascular abnormalities, systemic inflammation, and an increased risk of atherosclerotic disease. Survivorship guidelines should address cardiovascular concerns, including the risk of atherosclerotic disease and systemic inflammation, in exposed and unexposed survivors.

Myocardial function in offspring 5-8years after pregnancy complicated by preeclampsia

INTRODUCTION

Preeclampsia and diabetic pregnancies share pathophysiological features suggested to influence epigenetic changes during foetal life with importance for later development and metabolic and cardiovascular diseases.

AIM

Our objective was to study the myocardium in offspring after pregnancy complications.

METHODS

Forty-five children (age 5-8 years) delivered from pregnancies complicated by preeclampsia (n = 25), diabetes mellitus type 1 (n = 8) or gestational diabetes mellitus (n = 12) were included. Fifteen children from uneventful pregnancies served as controls. Myocardial functions of right and left ventricle were examined by conventional Doppler and tissue Doppler imaging (TDI).

RESULTS

No major differences were found in the myocardial function between offspring of pregnancy complications and control group. However, the preeclampsia group had smaller hearts, increased heart rate and increased late diastolic velocity (A'-wave) at mitral valve attachments shown by both pulsed wave and colour TDI compared to the control and diabetic groups together (p ≤ 0.01).

CONCLUSION

Children born after preeclampsia may show effects of a negative impact on the heart already at the age of 5 to 8 years. The numbers of examined children were, however, limited.