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P-wave Dispersion and Diastolic Function in Pubertal Type 1
Diabetic Children
P6:T1
Maha Amin1, Yasser Hussein Kamel2, Amany Ibrahim1, Fawzia Salim Ali Hamad
1 The Pediatric Department, Diabetes Endocrine and Metabolism Pediatric Unit (DEMPU), Children Hospital, Faculty of Medicine, Cairo University
2 The Pediatric Department, Pediatric Cardiology Unit, Children Hospital, Faculty of Medicine, Cairo University
Abstract
Background: Diastolic dysfunction is often the first manifestation of diabetic cardiomyopathy preceding the systolic damage and clinical signs of heart failure and which could be detected by echocardiography. In the adult
patient who has diastolic dysfunction an increased value of P-wave dispersion (PD) has been found. The increase in the P-wave dispersion in diabetic adolescents was discussed in few studies. Objective: To show the effect of
chronic hyperglycemia in type 1 diabetic adolescents on PD & diastolic function & to correlate the results to diabetes duration and complications. Subject and Method: Cross sectional, case control study included 50 pubertal
adolescents (28 ) males, ( 22) females with T1D of more than 5 years duration with age ranging from 9.5-19 years matched to 30 healthy control of same age and sex. All patients and controls were subjected to clinical
examination, anthropometric measurements, pubertal assessment, lipid profile, echocardiography and 12 leads ECG. Albumin creatinine ratio (Alb/creat) and fundus examination were done only for the patients. Results: Diastolic
dysfunction of both right and left ventricles and increased PD were found in patients. When correlating PD to echo parameters, a positive correlation was found between PD and LVEED (r = 0.3, p= 0.04). Significant negative
correlation was found between PD and both of A mitral and IVRT (r = -0.32, p=0.03 and r =-0.38, p= 0.01, respectively. Significant positive correlation was found between the duration of diabetes and IVRT (r =0.39, p = 0.02) &
significant negative correlation between the duration and E mitral and E/A ratio mitral (r = -0.38, p =0.01, and r = -0.29, p = 0.04, respectively). No correlation found to glycemic control, lipid profile, or Alb/ creat. Significant positive
correlation between LDL level and Alb/creat ratio(r =0.32, p =0.02). Conclusions: Increased PD in T1D patients make them prone to paroxysmal AF, diastolic dysfunctions are present in T1D patients and should be screened early
so not to progress to diabetic heart failure.
Results
Introduction
Objective
To show the effect of chronic hyperglycemia in type 1
diabetic children on P-wave dispersion (PD) & diastolic
function and to correlate the results with glycemic control,
diabetes duration and complications.
100.53
47.63
77.61
0.52
0.5
1.12
78.94
2.56
4.61
34.3
33
10.77
31.93
0.09
0.12
0.45
11.56
0.14
0.21
3.34
63.07
52.43
69.23
0.79
0.47
1.62
67.07
2.52
4.37
34.88
19.36
11.11
27.44
0.17
0.11
0.3
9.06
0.32
0.41
3.77
E tricuspid(m/sec)
0.6
0.07
0.66
0.07
A tricuspid(m/sec)
0.39
0.09
0.49
0.13
E/A ratio tricuspid
IVRTTR(mse)
P max (ms)
P min (ms)
PD
1.57
68.84
0.1
0.04
0.07
0.27
1.3
0.01
0.01
0.02
1.44
66
0.1
0.04
0.06
0.4
9.5
0.02
0.01
0.01
Fig (6):comparison between LDLin
T1D patients in relation to BMI.
P = 0.01
140
70
Patients and Methods
70
120
P = 0.05
dispersion in diabetic patients
r = - 0.3, P = 0.03
r = - 0.4, P = 0.01
P-value
0.07
0.08
0.002
0.6
0.02
0.0001
0.0001
0.0001
.12
.12
.10
.10
.08
.06
.04
.4
.5
Cardiac examination to detect any structural cardiac
abnormality & blood pressure measurement.
• Tests reflecting sympathetic damage: (Blood pressure
response to standing & Blood pressure response to
sustained handgrip).
C- Retrospective laboratory data were taken from patient
files, Complete blood count, HbA1c, Lipid profile,
Screening for microalbuminuria which is determined by
albumin/ creatinine ratio. Mean for last 3 month SBGM if
available.
D- Ophthalmological examination.
• ECG electrocardiography 12 lead to show the p-wave
dispersion and conventional echocardiography.
.6
.7
60
70
80
A mitral (m / sec)
0.06
0.2
0.0001
0.1
0.0001
0.0001
0.4
0.001
0.4
0.0001
dispersion in diabetic patients
pressure and E/A tricusped in diabetic patients
r = 0.3, P = 0.04
r = - 0.3, P = 0.02
.10
.08
.06
.04
.02
4.0
0.04
0.1
0.2
0.005
100
Fig (4): correlation between postural fall in blood
pressure
E/A tricuspid
in T1D
patients.
Fig 8:and
Correlation
between
postural
fall in blood
.12
0.1
90
IVRT (msec)
Fig (3): correlation between LVEDD and PD in
Figpatients.
7: Correlation between LVEDD and P wave
T1D
0.0001
30
4.2
4.4
20
10
0
4.6
4.8
-10
5.0
1.0
1.2
LVEDD (cm)
1.4
1.6
1.8
2.0
2.2
E/A tricusped
Fig 9: Correlation between albumin/ creatinine
Fig (5): correlation between alb/cr ratio and LDL in T1D patients.
ratio and
LDL
r =
in diabetic p atients
0.3, P = 0.02
200
100
88.75
69.5
100
0
69
60
0
10
20
30
Postural fall i n blood pressure
68.69
68.5
68.25
40
Recommendations
68
20
67.5
0
Normal
Overweight
Obese
67
Normal
Overweight
Obese
B- Examination including anthropometric measurement :
Weight, Height & BMI and their SDS, and Pubertal
assessment according to Tanner stages.
•
.04
96.34
80
A- History taking including: age and age of onset of
diabetes and its duration.
.06
.02
.3
-10
A Cross-sectional, case-control, prospective study included
50 children with T1D attending the outpatient DEMPU clinic
and they were compared to 30 healthy controls age and sex
matched. Patients were subjected to:
.08
.02
.2
Fig (6):comparison between IVRT tricuspid
in T1D patients in relation to BMI.
136.5
dispersion in diabetic patients
P wave dispersion
LDL (mg/dl)
HDL (mg/dl)
Tg (mg/dl)
E mitral(m/sec)
A mitral(m/sec)
E/A ratio
IVRT(mse)
LA(cm)
LVEDD(cm)
FS (%)
Variables
Age (yrs)
Weight (SDS)
Height (SDS)
BMI (SDS)
Hb (gm/dl)
HbA1 (%)
Total cholesterol (mg/dl)
Fig (2): correlation between IVRT and PD in T1D
Fig 6: Correlation between IVRT and P wave
patients.
Postural fall in blood pressure
•
Controls
Mean
SD
13.48
2.31
0.53
1.22
-0.27
0.94
0.40
1.67
12.62
1.03
5.36
0.68
100.4
19.7
Fig (1): correlation between A mitral and PD
Fig 5: Correlation between A mitral and P wave
in T1D
patients.
PDISPERS
•
Patients
Mean
SD
14.50
2.39
-0.03
1.56
-1.29
1.61
0.57
1.08
11.95
1.37
8.68
2.14
161.33
34.77
p wave dispersion
In T1D, the heart is subjected to a variety of pathological
insults including accelerated atherosclerosis, cardiac
autonomic
neuropathy
and
possibly
intrinsic
cardiomyopathy. Diabetic cardiomyopathy (DC) has been
proposed as diabetes specific complication. The most
important mechanisms of DC are probably metabolic
disturbances, microangiopathy , and myocardial fibrosis
(1).
Diastolic dysfunction is often the first manifestation of DC
preceding the systolic damage and clinical signs of heart
failure. Diastolic dysfunction results in an increased value
of P-wave dispersion (PD). PD is a measure of
heterogeneity of atrial refractoriness. In T1D, diastolic
dysfunction without any cardiac disorder as an early
finding of myocardial disease was reported (2).
The increase in PD is a known electrophysiologic marker
for the prediction of paroxysmal AF, making cardiac rhythm
disorders liable to occur in patients with T1D. AF may be
relatively common in diabetic patients and should be
regarded as a marker of adverse outcome promoting
aggressive management of all risk factors (3).
LDL (mg/dl)
•
Table (1): Comparison between demographic, anthropometric, laboratory
echocardiographic data, and p-wave characteristics, data of patients and controls
Conclusion
 Increased PD makes T1D patients prone to paroxysmal
atrial fibrillation.
 Diastolic dysfunctions are present in T1D patients and
should be screened early, so not to progress to
diabetic heart failure.
 Vigorous treatment of microalbuminuria may improve
lipid profile as well as the kidney and the heart.
 ECG may be used as rapid, easy, cheap, affordable method to screen for risk of paroxysmal
atrial fibrillation. PD can be used as an early marker to investigate for underlying still early
diastolic dysfunction before it progress to frank CHF due to the presence of correlation
between p wave & some of echocardiographic data.
 ECG may be used to screen diabetic patient with diastolic dysfunction and recommended for
echo investigation.
 Although our study revealed RV dysfunction by conventional Echocardiography but we
recommend TDI for both right as well as left ventricular dysfunction.
 Lipid profile may be used as a marker for renal impairment.
 Diagnosis of diastolic dysfunction is very important for early diagnosis, follow up, treatment,
and prognosis in heart failure diabetic patients.
 Careful blood glucose control is a critical defense against complication and is the path for
the improvement to their quality of life.
 As obesity is a modifiable cardiovascular risk factor, careful monitoring and management of
weight gain should be emphasized in diabetes care.
References
1. Retnakaran R , Zinman B (2008): Type 1 diabetes, hyperglycaemia, and the heart. The Lancet. 371, 1790 – 99.
2. 2. Freire CM, Moura AL, Barbosa Mde M, Machado LJ, Nogueira AI, Ribeiro-Oliveira A Jr (2007): Left ventricle diastolic dysfunction in diabetes: an update.
Arq Bras Endocrinol Metabol; 51: 168–175.
3. 3. Nichols GA, Reinier K, and Chugh SS (2009): Independent Contribution of Diabetes to Increased Prevalence and Incidence of Atrial Fibrillation.Diabetes
Care; 32: 1851–1856.