Download echocardiographic study of left ventricular diastolic dysfunction in

ECHOCARDIOGRAPHIC STUDY OF LEFT VENTRICULAR
DIASTOLIC DYSFUNCTION IN DIABETES MELLITUS IN A.J.
INSTITUTE OF MEDICAL SCIENCES, KUNTIKANA,
MANGALORE.
A. Brief resume of the study
(1). Need for the study
India leads the world with largest number of diabetic subjects earning the dubious
distension of being termed the “Diabetes capital of the world”.
Diabetic mellitus is a chronic progressive metabolic disease. It involves myocardium at
relatively early stage even before clinical manifestations become obvious. Diabetes
mellitus is associated with a multitude of cardiovascular complications, e.g., increased
incidence of atherosclerotic coronary artery disease, myocardial infarction, congestive
heart failure, coronary microangiopathy and systemic arterial hypertension. In addition,
structural myocardial involvement termed as diabetic cardiomyopathy may be there
which is suggested by clinical, epidemiological, and histological studies. Myocardial
involvement in diabetics may occur early in the course of disease, initially impairing
early diastolic relaxation and when more extensive, it causes decreased myocardial
contraction.
Diabetes mellitus incidence is raising and is becoming a severe health problem in
civilized countries. Since diabetes mellitus affects all cells, diabetes complications may
involve all organs. Therefore, diabetic patients are examined regularly for possible
development of Diabetic retinopathy, diabetic nephropathy and peripheral neuropathy.
However, little attention is paid for the study of heart function. More frequent incidence
of heart failure in diabetics even in the absence of ischemic heart disease, valvular heart
disease or another disorder outside diabetes, leads to the presumption that diabetes
mellitus unfavorably affects the heart muscle by its complications.
The study intends to assess echocardiographic detection of left ventricular diastolic
dysfunction in diabetes mellitus patients.
(2). Review of literature
C.M. Schannwell et al conducted a study to investigate whether young patients with
insulin-dependent diabetes mellitus and normal systolic left ventricular (LV) function
already show a diastolic LV dysfunction and an increased risk of arrhythmias. Methods:
Echocardiography was performed in 87 patients suffering from type I diabetes mellitus,
without known cardiac disease and in 87 controls. Even young patients with diabetes
mellitus suffer from a diastolic dysfunction while systolic ventricular function is normal.
Therefore, echocardiography with measurements of diastolic functional parameters
appears to be a sensitive method for evaluating the manifestation and course of early
diabetic cardiomyopathy.(1)
Marie Berkova et al conducted a study to evaluate the influence of diabetes mellitus on
left ventricular function. Using Doppler echocardiography study was conducted where in
a group of 49 young (20-32 years old) persons with type 1 diabetes mellitus and a group
of healthy age-matched men and evaluated the parameters of diastolic fillin of the left
ventricle(LV). There was a significant differences in peak velocity of early filling of the
left ventricle, peak velocity of late diastolic filling of LV, time velocity integral of peak
E, time velocity integral peak A, ratios, time E, time A, time E/time and duration of
isovolumic relaxation period. Despite significant differences of results were in the range
of valves for the healthy population. However in detailed analysis it was found that the
values measured in young (20-32 years old) persons with type 1 diabetes mellitus
corresponded with diastolic parameters of healthy men of the age of 50 years and more.
Thus, diabetes mellitus can influence the relaxation properties of the left ventricle.(2)
Shresthe NR et al conducted a study on echocardiographic evaluation of diastolic
function in asymptomatic type 2 diabetes, which included 100 asymptommatic patients in
type 2 diabetes with out evidence of coronary artery disease, congestive heart failure,
thyroid or overt renal disease. LVDD was evaluated by Doppler echocardiography, which
included the valsalva maneuver to unmask the pseudo normal pattern of left ventricular
filling. The prevalence of LVDD and its association with risk factors were assessed.
LVDD was much common in subjects with well controlled type 2 diabetes who are free
of clinically detectable heart disease. The high prevalence of this phenomenon in this
high risk population suggests that screening for LVDD in type 2 diabetes should include
procedure such a valsalva maneuver to unmask the pseudo normal pattern of left
ventricular filling.(3)
Rajesh Rajput et al conducted a study to assess cardiac function by echocardiography and
Doppler in patients of NIDDM before and after the control of hyperglycemia. This study
included 30 patients of uncomplicated type 2 diabetes mellitus and 30, age and sex
matched, healthy subjects. Systolic function of LV were with in normal range in all
patients. Diastolic dysfunction of LV was very common and was detected in 63% of
patients. None of the control subjects had systolic or diastolic dysfunction. Diastolic
dysfunction persisted even after control of hyperglycemia over 3 months duration. It is
suggested that all patients of NIDDM should be routinely and repeatedly subjected to 2Dechocardiography and Doppler assessment of cardiac functions in long term management
of this metabolic disease.(4)
Schiller NB et al conducted a study on subjects who underwent 2 D and Doppler
echocardiogram according to the recommendations of the American society of
echocardiography. Recordings were taken from patients standard left lateral decubitus
position in expiratory apnoea or quiet breathing by using a multi-hertz sector probe(2-4
Mhz). LV dimensions were measured with M mode. The measurements included intra
ventricular septal thickness, posterior wall thickness, left ventricular diameter at the end
of diastole and systole respectively. All these parameters were compared with diabetic
normotensive to diabetic hypertensive patients. Diabetic patients showed higher LV
diameter, LV volumes, wall thickness and LV mass. On the contrary, they showed lower
fractional shortening and EF. These differences were more clear when diabetes was
associated with hypertension.(5)
D C Raev conducted a study on, which left ventricular function is impaired earlier in the
evolution of diabetic cardiomyopathy by an echocardiography. In the study a total of 157
young(mean age 26.6 years) cardiac asymptomatic type 1 diabetic patients and 54 age
and sex matched healthy (nondiabetic) subjects were studied. Left ventricular function
was studied by M-mode echocardiography. Diastolic dysfunction was twice as common
as systolic dysfunction. Of diabetic patients with systolic dysfunction, 83% had impaired
diastolic function, whereas only 30% of diabetic patients with diastolic dysfunction had
systolic dysfunction. The findings indicate that myocardial damage in patients with
diabetes affects diastolic function before systolic function. The intentional assessment of
diastolic function is advisable for early detection of LV dysfunction before clinical
symptoms appear, with follow-up to detect further deterioration of cardiac status.(6)
(3). Objective of the study
To assess left ventricular diastolic dysfunction in diabetes mellitus with no overt cardiac
symptoms or signs by echo study with an intention to detect patients with left ventricular
dysfunction at an early stage.
B. Materials and methods
(1). Source of data
We will be conducting a study based on data studied over 1 year in AJIMS, with diabetic
mellitus with no cardiac symptoms.
(2). Methods of collection of data
Study Design: One year prospective study.
Sample: It is a hospital based study. Study is done on patients admitted with diabetes
mellitus.
Place: A.J. Institute Of Medical Sciences , Mangalore.
Duration: One year from December 2009 to November 2010.
Inclusion criteria:
1. Selection of patient is based on history of diabetes mellitus, clinical examination and
laboratory parameters.
2. Asymptomatic patients with minimum 5 years duration of diabetes mellitus.
3. Patients attending AJ Institute of Medical sciences as IN patients in medical ward.
Exclusion criteria:
1. Myocardial infarction by history.
2. Patients with angina pectoris.
3. Patients with heart diseases.
4. Patients with hypertension.
C. List of references
Left Ventricular
Diastolic Dysfunction as an Early Manifestation of Diabetic Cardiomyopathy. Clinic of
1. Schannwell C.M, Schneppenheim M, Perings S, Plehn G, Strauer B.E.
Cardiology, Pneumology and Angiology, Heinrich Heine University, Düsseldorf, Germany.
Cardiology 2002;98:33-39 (DOI: 10.1159/000064682).
2. Berkova Marie, Opavsky Jaroslav, Berka Zdenek, Skranka Vladimir, Salinger Jiri. Left
ventricular diastolic filling in young persons with type 1 diabetes mellitus. Biomed. Received april
2003. Papers 147(1) 57-61.
3. Shrestha NR, Sharma SK, Karki P, Shrestha NK, Acharya P. Echocardigraphic evaluation of
diastolic function in asymptomatic type 2 diabetes. Journal Nepal association 2009;48(173):20-3.
4. Rajput Rajesh, Jagdish, Siwach SB, Rattan A. Echocadiographic and Doppler assessment of
cardiac functions in patients of non-insulin dependent diabetes mellitus. JIACM 2002;3(2):164-8.
5.Sciller NB,Shah PM, Crawford M, Demaria A, Devereux R, Feigenbaum H, gutgesell H, Rechek
N, Sahn D, Schnittger I. Recommendations for quantitation of the left ventricle by 2-D
echocardiography. Journal of AMERICAN SOCIETY OF ECHOCARDIOGRAPHY. 1989 SepOct;2(5):358-67.
6. Raev DC. Which left ventricular function is impaired earlier in the evolution of diabetic
cardiomyopathy? An echocardiographic study of young type I diabetic patients. American
Diabetes association. Diabetes Care July 1994 vol. 17 no. 7 633-639.