Download Evaluation of Right and Left Ventricular Systolic and Diastolic

Suez Canal Univ Med J
Vol. 11, No. 1 , March, 2008
65 - 7 4
Evaluation of Right and Left Ventricular Systolic and Diastolic Function in Patients
with Type I Diabetes Using Echocardiography and Tissue Doppler Imaging
Ghada S EIshahedfl>,
KamaP,
MD, Mohamed I Ahmed(!>, MD, Nagham S El-Beblawy(2>, MD, Hanan M
MD, Magdy F lsmaieP>, MD, Ousama AS Bin Zheidan'",
03
MBBch
2
Departments of Cardiology ' ' and Pediatrics' ', Faculty of Medicine, Ain Shams University'' 2 ', Suez Canal
University'3'
Abstract
Background: Impairment of cardiac function in patients with type 1 DM represents one of the serious
complications and, if present, may affect the quality of life and prognosis of the disease. Conventional
and tissue Doppler echocardiographic imaging can predict early stage and progression of diabetic
cardiomyopathic changes.
Objective: The aim of this study is to assess the effect of type 1 diabetes on cardiac systolic and diastolic
functions in both ventricles in patients without evidence of coronary artery disease or hypertension.
Patients and Methods: The study included 30 patients with type 1 DM (18 females and 12 males) and
10 healthy individuals, their age 14.2±2.4 years, and diabetes duration of 5 years or more. Cardiac functions
were assessed by conventional echocardiography, and tissue Doppler imaging studies.
Results: The study showed thai there is statistically significant difference as regard end diastolic
volume (EDV), right ventricular wall thickness (RVWT), Peak systolic myocardial velocity (Sm) velocity
of inferior and septal segments of .LV, Peak late diastolic myocardial (Am) velocity and Em/Am ratio of
lateral segment of RV, between diabetic and non diabetic population. Also, there is significant negative
correlation of diabetes duration to Peak early diastolic myocardial velocity (Em) of anterior segment (r
= -0.492, p<0.006), Am of anterior segment (r = -0.355, p<0.048) and Em of septal segment of the left
ventricle in patient group (r = -0.448, p<0.013). No significant correlation between diabetes duration and all
other echo-cardiographic parameters, age or HgAlc level. Ventricular interaction was also demonstrated
since significant relations were found between right and left ventricular, diastolic and systolic, functional
indices, as regards (1) positive correlation between the mitral and tricuspid (E,A) velocities in diabetic
patients (r=0.371, p<0.044), (r=0.438, p<0.015) respectively, (2) positive correlation of Em/Am ratio of
the lateral segment of the RV to Em/Am ratio of the septal segment of LV (r =0.465 , p< 0.010), (3) positive
correlation of right ventricular end-diastolic diameter (RVEDd) to interventricular septum systolic diameter
(IVSs), (r= 0.401, p<0.028), posterior wall thickness at end systole (LVPWTs), (r=0.443, p<0.014) and'
(EDV) of LV (r=0.366, p<0.047). There were no significant correlation between age and HgAlc blood
level with Doppler (E/A ratios) and pulsed tissue Doppler (Em/Am ratios) of both ventricles in diabetic
population studied.
Conclusion: Patients with type 1 DM have impaired diastolic function, in both ventricles before the
development of myocardial systolic dysfunction when assessed with either conventional or tissue Doppler
imaging. These alterations in myocardial function were related to the duration of DM and may be attributed
to ventricular interdependence as well as the uniform effect of diabetes on cardiac function.
Recommendations: Serial echocardiographic assessment, and particularly tissue Doppler imaging, are
warranted in patients with type 1 DM to follow the progression from ventricular subclinical involvement to
the development of symptomatic ventricular dysfunction.
Keywords: Type I Diabetes, Diastolic Function, Tissue Doppler.
Introduction
Patients with diabetes mellitus have high
incidence of heart failure even in the absence of
ischemic, hypertensive or valvular heart disease.
The Framingham Heart Study demonstrated the
increased prevalence of congestive heart failure in
diabetic males (2.4:1) and females (5:1) aged 4574 years. This association was even stronger in
younger patients (ages <65 years), being fourfold
higher'in diabetic male patients and eightfold higher
65
66
in diabetic female patients than in non diabetic
subjects"1.
These epidemiologic observations have led to
the hypothesis that diabetes itself contributes to
myocardial damage, apart from augmenting the
effects of other diseases that result in myocardial
disease, such as ischemic and hypertensive heart
disease which affect mainly diastolic and to lesser
extent systolic myocardial function'2'. From a
limited number of studies performed in type
1 diabetic population, it is clear that most insulin
dependent diabetic patients have normal or even
hyper- dynamic left ventricular systolic function at
rest (3) . Whereas diastolic function and particularly
relaxation is impaired' 01 . It has been suggested
that left ventricular dysfunction in type 1 diabetic
patients may be related to structural myocardial
changes or to concomitant diabetic autonomic
neuropathy li). The right ventricle has an important
contribution to the overall cardiac function affecting
both the course and prognosis in patients with heart
failure'7,8',
The aim of this study is to assess the effect of
type I diabetes on cardiac systolic and diastolic
functions in both ventricles in patients without
evidence of coronary artery disease or hypertension
using conventional echocardiography, and tissue
Doppler imaging studies.
Patients and Methods
Study Population:
Group 1 (patient group) included 30 consecutive
patients with type 1 diabetes, attending the pediatric
diabetic outpatient clinic of Ain Shams University
Hospital from July 2007 to January 2008, there age
was 10 years or more, they have DM for five years or
more from the date of diagnosis. All diabetic patients,
were asymptomatic, with no clinical evidence of either
systolic or diastolic heart failure. Cardiac evaluation of
all patients was done in Cardiology Department, Ain
Shams University Hospital. Exclusion criteria included
clinical evidence of either systolic or diastolic heart
failure (symptomatic patients), Patients with coronary
artery disease or systemic hypertension and the use of
any medication other than insulin known to affect cardiac
functions such as digitalis, angiotensin converting
enzyme inhibitor, or B-blocker.
Elshahed et al.,
Group 2 (control group) included 10 healthy
individuals who were not diabetic and had no evidence
of cardiovascular disease by history analysis, physical
examination and echocardiography.
The study population was subjected to the following:
A. Careful and detailed history and clinical
examination
B. Laboratory assessment: Glycosylated hemoglobin
(HgAlc) was measured in all patients to evaluate the
degree of diabetic control.
C. Echocardiographic and Doppler studies:
Echocardiographic and Doppler examination were
performed using Wingmed Vivid 5 machine with 2.5 or
3.5 MHz phased array imaging transducer with pulsed
and continuous wave Doppler and color flow imaging
capabilities. All patients were examined in supine and
left lateral recumbent position.
1. Two-dimensional (2-D) echocardiography: The
patients were examined using the parasternal long axis
and apical views. The right ventricular end diastolic
diameter and free wall thickness were measured from ihe
two dimensional parasternal long axis view.
2. M-mode echocardiography: M-mode recordings
were made while the cardiac anatomy was visualized with
2D echocardiography from the parasternal view with ECG
monitoring the cardiac cycle. All the measurements of the
ventricular parameters were recorded using the leading
edge technique and following the recommendations of
the American Society of Echocardiography'''', where
each dimension was measured at both end diastolic
coinciding with "R" wave and end systole al the smallest
systolic dimension""1. The following measurements
were obtained from the M-mode guided pictures in the
parasternal short axis view: Left ventricular internal
dimensions both at end diastole and systole (LVIDd and
LVIDs), thickness of intervenlricuiar septal wall at end
diastole (IVSd), thickness of left ventricular wall at end
diastole (PWTd), all measured in cm.
3. M-mode calculations:
• Percent fractional shortening"":
F.S.% = LVIDd - LVIDs
LVIDd
•Left ventricular end systolic and end diastolic
volumes, using Teichnolz formula.
EDV = [It (2.4+LVIDd)] (LVIDd)3
ESV = [7/{2.4+LVlDs)] (LVIDs)3
Ventricular Functions in Diabetic Patients Using ECG and Doppler Imaging
67
where
Results
EDV = end diaslolic volume
/. Patient characteristics: Forty individuals were
included in this study, 30 patients with type 1 DM
(group 1); 18 females and 12 males and 10 lieallhy
subjects as control group (group 2); 6 females and
4 males. There age ranged from 10-18 yrs (14.3 ±
2.4). There was no significant difference between
both groups as regards age and sex.
ESV = end systolic volume"2'.
• Stroke volume (SV): It is the difference between
EDV and ESV) in ml; SV = EDV - ESV.
• Ejection'fraction: It is measured from M-inode echobased on Teichnolz for volume determination.
EF=EDV-ESV
EDV
4.
Conventional
Doppler
echocardiographic
measurements: The peak early mitral filling velocity (E),
peak mitral atrial velocity during late diastole (A) and
their ratio (A/E) were used as left ventricular diaslolic
function indices. The mitral diastolic flow tracing was
imaged in the apical four chamber view by using pulsed
Doppler echocardiography with sample volume sited at
■ the tips of mitral leaflets. Similarly for the evaluation
of the right ventricular diastolic function the peak early
tricuspid filling velocity (E), peak tricuspid atrial filling
velocity during late diastole(A), and their ratio (A/E) were
recordings and ..measurements were taken according to
the current standards of the practice of echocardiography
(Applelon recorded). Measurements were averaged
from three end expiratory cycles at a sweep speed of
100 mm/s.
5. Tissue Doppler Imaging measurements (TDI):
The same ultrasound machine was used to acquire color
tissue Doppler data using a high frequency acquisition.
The imaging angle was adjusted to ensure a parallel
alignment of the beam with the myocardial segment of
interest. From standard four chambers and two chambers
view resting tissue Doppler velocities within a 5x10mm2 sample volume were derived for the basal segment
of the septal, lateral, inferior and anterior left ventricular
wall and for lateral right ventricular wall. Myocardial
peak systolic (Sm), early diastolic filling (Em) and late
diaslolic atrial filling (Am) velocities were measured
offline using customized software (Echopac TDI, GE
Wingmed Vivid Five) and averaged for each cycle.
Statistical analysis: Statistical analysis was
performed using SPSS 11 for Windows. Numerical
values are expressed as mean ± SD. Continuous variables
are compared using the Student unpaired l test. The chisquare lest is used to compare frequency ratios between
groups. The results are considered statistically significant
when P<0.05.
2. Echocardigraphic data
1) M-mode and 2 D data
Left ventricle: There was no statistically
significant difference between both groups
regarding LV echocardiographic measurements.
There was increase in LVEDd, PWTd and PWTs
in patients than in control group, but this finding
did not reach statistical significance. There was
statistically significant higher EDV in patient group
than in control group. Although left ventricular
ejection fraction was higher in diabetic patients
than in controls, this finding did not reach statistical
significance (Table I).
Right ventricle: Right ventricular wall thickness
(RVWT), is significantly higher in the diabetic group
than control group (6.00*1.05 vs 4.9011.06, p=
0.007) while regarding the RVEDd ; the difference
is not statistically significant (28.60*3.71 vs
27.66i-2.67, p=0.39).
2) Doppler:
• Mitral and tricuspid valve Jlaw: There was no
statistically significant difference between both
groups for both milial and tricuspid valves flow
Doppler parameters (peak E, A and E/A ratio)
(Tables 11 and HI).
• Tissue Doppler assessment of Left ventricle:
The mean peak systolic wave by Tissue Doppler
of the basal inferior segment was lower in control
group than in patient group. This difference was
statistically significant (Table IV). However; there
was no statistically significant difference between
both groups regarding diastolic function indices. On
the other hand, there was no statistically significant
difference between both groups regarding mean
peak systolic and diastolic Tissue Doppler velocities
of the basal anterior, septal and lateral segments.
68
Elshahed et al.,
• Tissue Doppler assessment of right ventricle:
There was statistically significant difference
between both groups regarding late diastoiic atrial
filling velocity (Am) of the lateral segment of RV.
There was also statistically significant difference
between both groups regarding (Em/Am ratio) of
the lateral segment. Regarding the other parameters
(Sm, Em) of the lateral segment there was no
statistically differences between both groups (Table
V, figure 1).
• Variables affecting Echocardiographic data:
There was a negative correlation between the
duration of DM to (Em) of anterior segment, (Am)
of anterior segment and (Em) of septal segment of
the left ventricle in patient group. There were no
significant correlation between diabetes duration
and all other echocardiographic parameters, age and
HgAlc (Table VI and Fig. 2 a,b,c).
• Correlation
between
echocardiographic
parameters of both ventricles: There was significant
positive correlation between the mitral and tricuspid
E (r =0371, p=0.044) and A (r=0.438, p=0.015)
wave velocities in diabetic patients. There was no
significant correlation between mitral and tricuspid
E/A ratios. There was statistically significant
positive correlation of Em/Am ratio of the lateral
segment of the RV to Em/Am ratio of the septal
segment of LV (r=0.465, p=0.010). No significant
correlation of Em/Am ratio of the lateral segment
of RV to Em/Am ratio of the other segments of LV
(Fig 3).
There is
statistically significant positive
correlation of right ventricular end-diastolic
diameter (RVEDd) to interventricular septum
systolic diameter (IVSs), posterior wall thickness
at end systole (LVPWTs) and end diastoiic
volume (EDV) of LV. There was no significant
correlation of (RVEDd) to other M-mode and
2D echocardiographic parameters of LV. There
was no significant correlation of right ventricular
wall thickness (RVWT) to all M-mode and 2D
echocardiographic parameters of LV (Table VII).
There is no statistically significant correlation of the
age to mitral, tricuspid E/A ratios and Em/Am ratios
of both ventricular segments in diabetic population
studied (Table VIII). There is no statistically
significant correlation of HgAlc to mitral, tricuspid
E/A ratios and Em/Am ratios of both ventricular
segments in diabetic population studied.
Table (I): Comparison between LV Echocardiographic findings in both groups
LVEDd
LVEDs
IVSd
IVSs
LVPWTd
LVPWTs
EDV
ESV
EF
* Significant: P<0.05
Group 1
Group 2
42.80±2.30
28.90±2.60
6.00±0.66
9.J0±0.73
6.40±0.69
I0.40±1.35
70.00±8.66
30.30±2.00
66.70±.005
43.46±4.83
27.16i4.21
6.36±1.54
9.70±1.64
6.83±1.23
11.30±1.78
85.65±23.38
29.19±10.52
67.10±5.76
T test
P value
0.67
0.23
0.30
0.27
0.30
0.15
0.004*
0.74
0.84
t
-0.41
1.22
-1.04
-1.11
1.04
1.45
-3.08
0.32
-0.20
Table (II): Comparison behveen mitral flow Doppler parameter in both groups
Peak E (m/s)
Peak A (m/s)
E/A ratio
Group 1
Group 2
1.01±0.14
0.70±0.14
1.47±0.35
1.06±0.14
0.70±0.16
1.57±0.45
Ttest
t
P value
0.30
0.95
0.51
-1.04
-0.05
-0.65
Table (III): Comparisori behveen tricuspid flow Doppler parameter in both groups
Peak E (m/s)
Peak A (m/s)
E/A ratio
Group 1
Group 2
0.86±0.19
0.65±0.17
1.32±0.16
1.06±0.14
0.55±0.13
1.34±0.30
T test
t
1.98
1.86
-0.21
P value
0.055
0.07
0.83
69
Ventricular Functions in Diabetic Patients Using ECG and Doppler Imaging
Table (IV): LV pulsed tissue Doppler findings in patients and controls (inferior segment)
SM (cm/s)
Group 1
Group 2
5.00±1.33
6.38±2.47
-2.96
P value
EM(cm/s)
9.90±2.07
9.83±2.39
0.07
0.9.1
AM(cm/s)
3.10±0.S7
4.26±2.11
1.68
0.10
EM/AM ratio
3.36±0.95
2.74±1.07
1.62
0.11
Significant: P<0.05
Table (V): RV pulsed tissue Doppler findings in both groups (lateral segment)
T test
Group 1
Group 2
SM (cm/s)
8.70±1.25
9.80±2.31
-1,42
0.19
f
P value
0.16
EM(cm/s)
10.90±2.23
9.40±3.37
1.30
AM(cm/s)
4.00±0.8I
7.16±3.05
-3.70
0.004*
EM/AM ratio
2.90±1.19
1.76±1.32
2.53
0.02*
• Significant: P<0.0
Table (VI): Correlation of duration of disease to age, LV, RV M-mode, 2D Doppler tissue Doppler parameters and
HgAlc among diabetic patients
r
P-value
Age
0.295
0.114
LVEDd
-0.135
LVEDs
Duration
Duration
r
P-vnluc
AM (inf)
-0.088
0.477
EM/AM (inf)
0.181
0.643
0.339
-0.114
0.549
anlSM
0.137
0.471
lVSd
-0.063
0.742
EM (ant)
-0.492
0.006*
IVSs
0.018
0.924
AM (ant)
-0.355
0.048*
LVPWd
0.151
0.427
EM/AM (ant)
-0.203
0.283
LVPWs
EDV
-0.084
0.658
sepSM
0.119
0.532
-0.126
0.508
EM (sep)
-0.448
0.013*
ESV
-0.121
0.523
AM(Sep)
0.061
0.748
EF%
0.105
0.581
EM/AM (sep)
-0.075
0.694
RVEDd
-0.030
0.876
SM (lat)
0.299
0.108
RVWT
-0.200
0.291
EM (lal)
-0.227
0.227
E (mitral)
0.015
0.937
AM (lal)
0.209
0.268
A (mitral)
0.169
0.372
EM/AM (lat)
-0.090
0.637
E/A (mitral)
-0.204
0.279
RVlatSM
0.063
0.739
E (tricuspid)
0.174
0.359
EM (Rvlat)
-0.286
0.126
A (tricuspid)
0.245
0.192
AM (Rvlat)
-0.232
0.217
E/A (tricuspid)
-0.096
0.614
EM/AM (Rvlat)
0.158
0.403
infSM
EM (inf)
0.117
0.538
0.762
HgAlc
-0.029
0.880
-0.058
Elshahed et a l ,
70
Table (VII): Correlation of (RVEDd) , (RVWT) to the LV M- mode and 2D echocardiogra phic parameters in
diabetic patients
Correlations
RVWT
RVEDd
r
P-value
r
P-va lue
LVEDd
0.258
-0.240
0.198
0.181
0.295
LVEDs
0.168
0.201
IVSd
0.047
0.803
0.044
0.817
IVSs
0.401
0.028*
0.081
0.670
LVPWd
0.051
0.790
-0.002
0.992
LVPWs
0.443
0.014*
-0.092
0.628
EDV
0.366
0.047*
0.022
0.906
ESV
0.306
0.101
1.000
0.044
0.816
0.081
0.672
EF%
0.000
0.338
* Significant P<0.05
Table (VIII): Correlation of age and IIAlc to (E/A), (Em/Am) ratios of LV and RV in diabetic patients
Age
HgAlc
P-value
r
P-value
-0.323
-0.426
0.082
0.126
0.507
0.019
-0.093
0.623
EM/AM(inl)
0.151
0.426
0.136
0.472
EM/AM(ant)
-0.078
0.682
0.203
0.281
EIM/AM(sep)
-0.267
0.153
0.280
0.134
EM/AM(lat)
-0.039
0.837
0.168
0.375
E1VI/AM(RV Iar)
-0.312
0.094
-0.139
0.463
E/A(mirral)
E/A(tricuspid)
(Figure 1): Pulsed wave tissue Doppler velocities (Sm, Em, & Am) of the lateral wall of RV, Am>Em velocity (reversed)
denoting diastolic dysfunction of the RV
71
Ventricular Functions in Diabetic Patients Using ECG and Doppler Imaging
r=-0.492
■ ^
P-value=0.006*
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r=-0.355
««
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a
12
12'
c
P-value=0.048*
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it
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It
It
12
14
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Fig. (2a): Significant negative correlation between
diabetes duration and Em velocity of the anterior
segment of LV in diabetic patients.
P-value*0.013*
n*-0.448
it
R it *S«
Fig. (2b): Significant negative correlation between
diabetes duration and Am velocity oT the
anterior segment of LV in diabetic patients.
r=0.465
P-valu8=0.010*
*
« *
*
u
N
i:
H
M
*
*
*
*
*
*
tt
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•
10
12
14
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l*^*«^
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4
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2
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9
ft1
EM(«p)
Fig. {2c): Significant negative correlation between
diabetes duration and Em velocity of the scptal
segment of LV in diabetic patients.
Discussion
Diabetic cardiomyopathy is defined as a clinical
entity characterized by the presence of myocardial
function abnormalities with or without cardiac
insufficiency, in absence of coronary atherosclerosis,
valvular diseaseor arterial hypertension{13J. However,
the presence of cardiac abnomialities in young
patients with (type 1 DM) is controversial. The
use of non invasive methods such as conventional
Doppler and tissue Doppler echocardiography,
correlate favorably with other invasive technique,
this has enabled us to study asymptomatic groups
with no need to more invasive methods.
In the present study cardiac function was sr died
in a group of patients with type 1 DM IPJ the
effect of age, duration of diabetes, and glycti-ylcited
haemoglobin on echocardiographic, Doppler and
tissue Doppler parameters were assessed.
EMMM(Mp0
Fig.(3): Significant positive correlation between
Em/Am ratio of lateral segment of HV and
Em/Am ratio of the scptal segment of LV in
diabetic patients
The present study showed that PWTd and
PWTs were higher in diabetic patients than in
controls, but this finding did not reach statistical
significance. This disagrees with Airaksinen et
al.tM1 who found that both interventricular septum
and posterior wall thickness increased significantly
in diabetic patients. This increase in LV wall
thickness could be due to action of insulin hormone
which stimulates the formation of protein from
amino acid and accumulation of protein within the
cellstl5). The other cause of increase posterior wall
thickness was the potential role of growth hormone.
Patient with difficult to control diabetes often have
increased growth hormone levels and this metabolic
abnormality could account for increased collagen
level present in left ventricular wall of diabetic
humans and animals06'. This discrepancy is most
likely related to the smaller number of diabetic
72
patients, with a significantly shorter duration of
diabetes in this study.
This study showed significant difference
between the diabetic and control groups regarding
left ventricular end diastolic volume (EDV). It was
found to be increased in diabetic group. This is in
agreement with some studies117'1*0 who found that
stroke volume significantly increased in diabetic
patients while another study(l4) found that stroke
volume is significantly decreased in diabetic
patients with severe complications. The increase
in EDV in the present work could be related to the
increased LVEDd, with no significant change of LV
end systolic diameter and volume.
We have shown in the present study that not
only left ventricular but right ventricular diastolic
function is impaired with type 1 diabetes mellitus
with no evidence of coronary artery disease or
hypertension. Although conventional Doppler failed
to show any difference in E/A ratio among diabetic
patients and normal subjects, for either left or right
ventricle, TD1 showed abnormal diastolic filling
patterns were reflected by significantly increased
myocardial systolic velocity (Sm) of inferior and
septal segments of left ventricle and late diastolic
atrial filling velocity (Am) and decreased Em/Am
ratio of the lateral segment of right ventricle in
diabetic patients.
As faras left vcntricularfunction is concerned, this
is a well known finding in consistent with previous
conventional Doppler studies in typel diabetic
population that showed abnormal diastolic filling
patterns (relaxation abnormality)14'5'. However,
very limited data exist for right ventricular diastolic
function in this specific diabetic population.
A recent study(l9) reported right ventricular
diastolic dysfunction in a non uniform, type 1
and type 2, diabetic cohort using TDI, although
conventional Doppler failed to show any difference
in E/A ratio among diabetic patients and normal
subjects. This finding agrees with our study, where
only tissue Doppler revealed significant differences
in right ventricular diastolic filling patterns.
Also, another recent study120' reported right
ventricular diastolic dysfunction in typel diabetic
patients when compared with normal subjects.
This agrees with our study that showed significant
Elshahed et al.,
difference between both groups regarding late
diastole atrial filling velocity (Am) of the lateral
segment of RV. They disagree with our study that
conventional Doppler failed to show any difference
in E/A ratio a many diabetic patients and normal
subjects.
In our study, we did not evidence any impairment
in left ventricular systolic function in type 1 diabetic
patients at rest, with either ejection fraction (EF%),
conventional or tissue Doppler echocardiography.
Tissue Doppler detects changes in specific, diseased
regions, even when the function of other segments
or entire chamber is still normal, as reflected by
increased (Sm) of inferior and septal segments of
LV in diabetic patients.
Recent tissue Doppler studies1'1-1'21"23' agree with
our study. They reported the existence of subtle
systolic changes of regional LV function mainly
detected with mitral annulus systolic velocities,
strain and strain rate in diabetic patients either at rest
or during stress. However, these studies included,
either exclusively or mainly, type 2 diabetic patients
with older ages compared to our study population.
Age is an important factor associated with left
ventricular dysfunction and had not been taken into
account in the determination of functional status in
these studies, However our results were consistent
with Nikitin et al.(24) and showed no significant
correlation between the age and mitral ,tricuspid
ratios and Em/Am ratios of both ventricles among
diabetic patients regarding diastolic function.
Regarding right ventricle, the echocardiographic
assessment of right ventricular systolic function is
difficult because of its complex geometric shape.
Tissue Doppler imaging has become an alternative
method in the assessment of systolic RV function.
Although global RV systolic function was not
assessed in our study, regional RV systolic function,
evaluated by color tissue Doppler systolic velocity
(Sm) of the lateral segment of RV, was unimpaired
in diabetic patients. This findings are in agreement
with other studies1 l'J'20'25'.
Regarding the correlation between the duration
of diabetes and the LV and RV function indices,
our study showed significant negative correlation
with regional LV diastolic function of anterior
segment (Em, Am) and septal segment (Em), and no
Ventricular Functions in Diabetic Patients Using ECG and Doppler Imaging
correlation with LV systolic function, regarding the
RVfunctionno correlation either systolic or diastolic.
This Finding is in agreement with Karamitoses et
al."7'who showed a negative correlation between
the duration and the systolic, diastolic functions of
LV and diastolic function of R.V.
Our study showed significant correlation between
right ventricular and left ventricular, diastolic and
systolic, functional indexes, the same results was
found in other studies'20-26,27'. These studies showed
that the two ventricles are anatomically united by
their common blood supply, muscle fiber anatomy,
interventricular septum and pericardium'261, and
exhibit interdependence as already demonstrated in
other condition such as arterial hypertension'273In our study, we did not evidence any correlation
between HgAlc and LV, RV diastolic function, on
the contrary, Devereux et al.12*1 showed that the
extent and frequency of diastolic dysfunction was
directly proportional to the HgAlc level likely
because of the accumulation of advanced glycation
end products (AGEs) in the myocardiuml29).We
believe that this discrepancy is most likely related
to differences in study populations, since our patient
group consisted of sole type 1 diabetic patients, with
relative longer duration of diabetes. Both apoptosis
and myocardial fibrosis have been identified in
diabetes, reflecting hormonal changes, involving
angiotensin and aldosterone(30).
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Correspondence to:
Ghada Samir Elshahed
Departments of Cardiology,
Faculty of Medicine,
Ain Shams University, Cairo, Egypt.
E-mail: [email protected]
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Dell, Italia LJ
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