Clinical Investigation
LV Strain
Prognostic Value of Early Systolic Lengthening by Strain Imaging in Type 2 Diabetes

https://doi.org/10.1016/j.echo.2020.09.008Get rights and content

Highlights

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    ESL is a paradoxical lengthening of myocardial fibers.

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    ESL (magnitude and duration) may be assessed by speckle-tracking echocardiography.

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    ESL was assessed in the setting of type 2 diabetes with no history of heart disease.

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    ESL was a predictor of cardiac events in patients with reduced longitudinal strain.

  • •

    ESL may represent a novel parameter for risk stratification of type 2 diabetes.

Background

Patients with type 2 diabetes (T2D) have increased risk for subclinical myocardial disease. Early systolic lengthening (ESL), a paradoxical stretch of myocardial fibers, is a sensitive marker of myocardial dysfunction. The aims of this study were to investigate the prognostic value of ESL in patients with T2D and to determine if global longitudinal strain (GLS) modifies this relationship.

Methods

In this prospective study, speckle-tracking echocardiography was conducted in 703 patients with T2D (62% men; mean age, 63 ± 10 years; median diabetes duration, 11 years; interquartile range, 6–17 years). Patients had no histories of significant heart disease. ESL index was assessed as [−100 × (peak positive systolic strain/maximal strain)] and ESL duration as time from QRS complex on the electrocardiogram to time of peak positive systolic strain. P values ≤ .004 were considered to indicate statistical significance.

Results

During a median follow-up time of 4.8 years (interquartile range, 4.1–5.3 years), 86 patients (12%) experienced major adverse cardiovascular events (MACE), a composite of incident heart failure, myocardial infarction, and cardiovascular death. In multivariate models, only the ESL index (hazard ratio [HR], 1.06 per 1% increase; 95% CI, 1.01–1.010; P = .004) but not ESL duration (HR, 1.02 per 1-ms increase; 95% CI, 1.00–1.03; P = .036) were associated with MACE. GLS modified this relationship (P for interaction < .05) such that in patients with low GLS (>−18%), ESL index (HR, 1.06 per 1% increase; 95% CI, 1.02–1.10; P = .003) was associated with MACE, but ESL duration was not (HR, 1.02 per 1-ms increase; 95% CI, 1.00–1.04; P = .005). No associations were found for high GLS (<−18%).

Conclusions

In patients with T2D and no histories of heart disease, ESL provides prognostic information on MACE and may potentially aid in cardiovascular risk stratification.

Section snippets

Population

The Thousand&2 study population is a prospective and longitudinal cohort study of patients with type 2 diabetes initiated in 2011 at two secondary health care centers in Denmark: Steno Diabetes Center Copenhagen and the Center for Diabetes Research (now the Steno Diabetes Center Copenhagen), Gentofte Hospital, University of Copenhagen. This was a secondary analysis of the Thousand&2 study cohort, and the study protocol has previously been described and baseline results previously been published.

Results

Baseline clinical characteristics stratified according to tertiles of ESL index are displayed in Table 1. Patients with high ESL index more frequently were female, had hypertension, and had higher glycated hemoglobin, higher LV mass index, and lower GLS. No difference in age or known duration of diabetes was observed across tertiles of ESL index. Similar characteristics applied to tertiles of ESL duration (Supplemental Table 1). Histograms of the distributions of ESL parameters, postsystolic

Discussion

Patients with type 2 diabetes frequently have asymptomatic cardiovascular disease, and their prognosis is significantly poorer compared with that of individuals without diabetes.20,21 Consequently, cardiovascular risk stratification remains a core challenge in this population. In this study, we found that assessment of ESL, a paradoxical lengthening of myocardial fibers in systole, provided independent prognostic information on MACE in patients with type 2 diabetes. Furthermore, we found that

Conclusion

Assessment of ESL on speckle-tracking echocardiography provides novel and independent prognostic information on adverse cardiovascular events in patients with type 2 diabetes. The prognostic value was enhanced in patients with reduced GLS. Future clinical studies are required to confirm our findings.

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    Dr. Brainin was supported by a research grant from The Independent Research Fund Denmark (0129-00003B). Dr. Biering-Sørensen is a member of the steering committee of the Amgen-financed GALACTIC-HF trial; has served on the advisory boards of Sanofi Pasteur and Amgen; and has received speaker's honoraria from Novartis and Sanofi Pasteur. Dr. Jensen has served as consultant, on advisory boards, or as in invited speaker for AstraZeneca, Novo Nordisk, Novartis, and GE. Dr. Vilsbøll has received personal fees from Amgen, Boehringer Ingelheim, Eli Lilly, AstraZeneca, Novo Nordisk, Merck, Mundipharma, Sanofi, and Sun Pharma; and has received grants (to her institution) from Eli Lilly, Boehringer Ingelheim, and Novo Nordisk. Dr. Rossing has received consulting and/or speaking fees (all to Steno Diabetes Center Copenhagen) from Astellas, AstraZeneca, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Gilead, Eli Lilly, Merck, Mundipharma, Novo Nordisk, and Sanofi Aventis; has received research grants from AstraZeneca and Novo Nordisk; and holds shares in Novo Nordisk. Dr. Jørgensen has received lecture fees from Novo Nordisk and Astra Zeneca.

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    2020 Published by Elsevier Inc. on behalf of the American Society of Echocardiography.