Diabetes with cardiomyopathy (DbCM) puts patients at high risk of developing heart failure, regardless of the criteria used to define cardiomyopathy, according to a new analysis of subjects from three U.S. cohort studies.
The findings were published Monday online by Matthew W. Segar, MD, MS, from the University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, together with colleagues, ahead of the Oct. 19 issue of the Journal of the American College of Cardiology.
Cardiovascular disease is a leading cause of death in diabetics, with heart failure accounting for a large proportion of the initial presentations of heart issues for these people. Heart failure risk persists despite optimal control of traditional risk factors, the researchers added.
However, optimal criteria for the identification of DbCM and its prognostic implications for the risk of incident heart failure are not well-established, they said.
The current study, therefore, set out to review DbCM prevalence in 2,900 patients from the U.S. ARIC (Atherosclerosis Risk In Communities), CHS (Cardiovascular Health Study) and CRIC (Chronic Renal Insufficiency Cohort) epidemiological cohort studies.
DbCM was defined using three different definitions: least restrictive, with ≥1 echocardiographic abnormality (left atrial enlargement, left ventricle hypertrophy, diastolic dysfunction); intermediate restrictive, with ≥2 echocardiographic abnormalities; and most restrictive, with elevated N-terminal pro–B-type natriuretic peptide levels (>125 in normal/overweight or >100 pg/mL in obese) plus ≥2 echocardiographic abnormalities.
At baseline, participants were of similar age across all three definition groups (a mean of 72 years in the least restrictive group, 71 years in intermediate and 72 years in most restrictive), were 41.4%, 32.8% and 35.% male respectively, and the majority had hypertension (61.3%, 62.9% and 69.2% respectively). Those with DbCM were more commonly Black (27.9% in least restrictive, 30.9% in intermediate and 27.8% in most restrictive).
Participants diagnosed with DbCM per the most restrictive criteria had a greater burden of CVD risk factors including greater rates of hypertension (69.2% vs. 61.3% in least restrictive), worse kidney function (eGFR, mL/min/1.73 m2 57 ± 25 vs. 65 ± 24), and higher levels of high-sensitivity cardiac troponin (hscTnT) (mean of 17 pg/mL vs. 13 pg/mL) and B-type natriuretic peptide (BNP) levels (mean of 89 pg/mL vs. 34 pg/mL).
Use of the least restrictive criteria increased the prevalence of DbCM almost 3-fold compared with the most restrictive criteria, from 11.7% in the most restrictive group, to 20% in intermediate and 67% for the least restrictive cohort.
The 5-year cumulative incidence rates of heart failure in patients with DbCM was 8.4% in the least restrictive group, 11.2% in intermediate and 12.8% for the most restrictive criteria.
The 67% of patients with DbCM per the least restrictive definition accounted for 78.5% of all heart failure events among participants with diabetes over 5 years of follow-up, compared to the 11.7% with DbCM per the most restrictive definition, who accounted for 21% of heart failure events over 5 years.
Increasing levels of body mass index and age, and lower estimated glomerular filtration rate (eGFR) values were also associated with a higher probability of DbCM across all criteria.
Regardless of the criteria used, participants with DbCM were at significantly higher risk of incident heart failure than those with normal blood sugar levels.
Nevertheless, the highest risk was observed for the most restrictive definition of DbCM (hazard ratio [HR]: 2.55; 95% confidence interval [CI]: 1.69-3.86), versus a hazard ratio of 1.99 for the least restrictive criteria (95% CI: 1.50-2.65).
“A similar pattern of results was observed across cohort studies, across sex and race subgroups, and among participants without hypertension or obesity,” the researchers noted.
Irrespective of the criteria for diagnosis, the results show that “those with diabetes are at increased risk of developing clinical [heart failure],” the researchers concluded, calling for additional studies to evaluate specific therapies to reduce the risk of heart failure among patients with diabetes and cardiomyopathy.
However, editorialists warned against labeling DbCM unduly.
“While expanding screening via cardiac biomarkers and imaging before onset of HF symptoms may seem appealing, the lack of generalizable, uniform, and practical diagnostic criteria in otherwise asymptomatic individuals risks unwarranted labeling of disease,” Vanita R. Aroda, MD, from Brigham and Women’s Hospital and Harvard Medical School, Boston, and colleagues said in an accompanying editorial.
Segar MW, Khan MS, Patel KV, et al. Prevalence and Prognostic Implications of Diabetes With Cardiomyopathy in Community-Dwelling Adults. J Am Coll Cardiol 2021;78:1587-1598.
Aroda VR, Taub PR, Stanton AM. Diabetes With Cardiomyopathy: At the Juncture of Knowledge and Prevention. J Am Coll Cardiol 2021;78:1599-1602.
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