Diabetes Mellitus Associated with Changes in Heart Structure

Dr. Jonathan Yap, MBBS, MPH

New research is suggesting type 2 diabetes (T2D) mellitus could impact heart structure and increase the risk of complications and death among patients with heart failure.

After analyzing patients from the Asian Sudden Cardiac Death in Heart Failure (ASIAN-HF) registry, investigators found T2D mellitus was associated with structural changes, poorer quality of life, and worse outcomes among patients with HF and reduced ejection fraction (HFrEF) and patients with HF and preserved ejection fraction (HFpEF). 



With previous studies showing a potential association between T2D mellitus and cardiac remodeling, investigators sought to examine the association between the disease and cardiac remodeling, quality of life, and clinical outcomes in Asian patients with HFrEF and HFpEF. Additionally, the study was designed to review interactions between T2D and HF according to various HF phenotype.

For the analysis, T2D mellitus was defined as having a clinical diagnosis or a self-report history of diabetes mellitus. All patients included in the cohort received a transthoracic echocardiography (ECG) and 12-lead ECG at baseline. 





Investigators defined HFrEF as ejection fraction less than 40% and HFpEF as those with ejection fraction 50% or greater at baseline. Outcome measures for the study included all-cause mortality and the composite of all-cause mortality or HF hospitalization, each at 1 year. Quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ).

A cohort of 6167 patients were identified from the ASIAN-HF registry. Of that group, 5028 had HFrEF and 1139 had HFpEF. Investigators used 965 participants of the Singapore Heart Failure Outcomes and Phenotypes (SHOP) study without HF as a control arm for comparisons.

Of those with HFrEF, 78.2% were men, the mean age was 60 years, and the mean left ventricular ejection fraction (LVEF) was 23.7%. Among the HFpEF group, 50.3% were men, the mean age was 68.2 years and the mean LVEF was 61%.

Investigators noted that the prevalence of T2D mellitus was increased in the HFpEF (45%) group compared with those in the HFrEF group. Additionally, the average duration of diabetes mellitus was longer in those with HFpEF (12 years) compared to patients with HFrEF (9.8 years).

Using adjusted Cox proportional hazards models, investigators found both diabetes mellitus was associated with smaller index left ventricular diastolic volumes and higher mitral E/e’ ratio. In patients with HFrEF, investigators noted a predominance of eccentric hypertrophy, while a a predominance of concentric hypertrophy was noted in patients with HFpEF. 



Investigators also noted patients with diabetes mellitus had lower scores on the KCCQ in both the HFpEF and HFrEF groups — with more differences being noted in the HFpEF group. Across both groups, patients with diabetes mellitus had more HF rehospitalizations (aHR, 1.27; 95% CI, 1.05—1.54; P = 0.014) and higher 1-year rates of the composite all-cause mortality and HF hospitalization (aHR, 1.22; 95% CI, 1.05—1.41; P=0.011) — no differences were noted between the HFpEF and HFrEF groups.

"Primary prevention strategies and tailored treatment options are needed to tackle this twin scourge of diseases," said Jonathan Yap, MBBS, MPH, study investigator and consultant from the department of cardiology of the National Heart Centre Singapore. "Our findings emphasize the need for preventative public health measures at the community and primary care level. For heart failure patients who have diabetes, physicians should closely monitor and optimize their management."

This study, “Association of Diabetes Mellitus on Cardiac Remodeling, Quality of Life, and Clinical Outcomes in Heart Failure With Reduced and Preserved Ejection Fraction,” was published online in the Journal of the American Heart Association.