ECHOCARDIOGRAPHIC STUDY OF LEFT VENTRICULAR …



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 2D-

echocardiography 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

1. Schannwell C.M, Schneppenheim M, Perings S, Plehn G, Strauer B.E. Left Ventricular Diastolic Dysfunction as an Early Manifestation of Diabetic Cardiomyopathy. Clinic of 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 Sep-Oct;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.

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