Clinical Outcomes and Prognosis
Noor Sharrack, MBChB, MRCP, DTM&H
Clinical Research Fellow
University of Leeds, England, United Kingdom
Louise A. Brown, PhD
Clinical Research Fellow
Leeds Institute of Cardiovascular and Metabolic Medicine
Leeds, England, United Kingdom
Jonathan Farley, BSc, MB
Cardiology
University of Leeds, United Kingdom
Ali Wahab, BSc
Cardiology registrar
University of Leeds
Leeds, England, United Kingdom
Nicholas Jex, MD
PhD Fellow
Leeds Institute of Cardiovascular and Metabolic Medicine, England, United Kingdom
Sharmaine Thirunavukarasu, MbCHB
Cardiology
University of Leeds
WILMSLOW, England, United Kingdom
Amrit Chowdhary, MD
Cardiology
University of Leeds
WAKEFIELD, England, United Kingdom
Miroslawa Gorecka
Cardiology
University of Leeds, United Kingdom
Wasim Javed, MBChB, MRes
Cardiology Clinical Research Fellow/ Registrar
Leeds Institute of Cardiovascular and Metabolic Medicine, United Kingdom
Hui Xue, PhD
Director, Imaging AI Program
National Institutes of Health
Bethesda, Maryland, United States
Eylem Levelt, PhD
Associate Professor and Honorary Consultant
University of Leeds
Leeds, England, United Kingdom
Erica Dall’Armellina
Associate Professor and Honorary Consultant Cardiologist
University of Leeds, England, United Kingdom
Peter Kellman, PhD
Senior Scientist
National Institutes of Health, Maryland, United States
Pankaj Garg, PhD
Associate Professor of Cardiovascular Medicine
University of East Anglia, United Kingdom
John P. Greenwood, PhD
Professor
University of Leeds
Leeds, England, United Kingdom
Sven Plein, MD, PhD
Professor
University of Leeds
Leeds, England, United Kingdom
Peter P. Swoboda, PhD
Consultant Cardiologist & Senior Lecturer
University of Leeds
Leeds, England, United Kingdom
Diabetic patients with heart failure (HF) have worse outcomes compared to normoglycaemic HF patients. Patients with diabetes mellitus (DM) are at increased risk of ischaemic heart disease (IHD), silent myocardial infarction (MI) and coronary microvascular dysfunction (CMD). All of these can be assessed and quantified using cardiac magnetic resonance (CMR), including most recently quantitative myocardial blood flow (MBF). We aimed to investigate whether outcomes in diabetic HF patients without known IHD are mediated by silent IHD or CMD.
Methods:
Prospectively recruited outpatients with a recent diagnosis of HF underwent perfusion CMR (3T Siemens Prisma) for calculation of myocardial perfusion reserve (MPR) using the technique described. All patients were divided into groups depending on their HbA1c level or a known diagnosis of DM (normoglycaemia, pre-diabetes and diabetes). Exclusion criteria included anginal chest pain or history of IHD. Silent IHD was defined as inducible ischaemia or MI on CMR. Patients were followed up (median 3.0 years) for all cause death and major adverse cardiovascular events (MACE) which included CV death, acute coronary syndrome (ACS), non-fatal MI, non-fatal stroke, HF hospitalisation and ventricular arrhythmia.
Results:
Final analysis included 343 patients (176 normoglycaemic, 84 pre-diabetic and 83 diabetic). The prevalence of silent IHD, was highest in diabetic patients (31.3%) compared to prediabetic patients (20.2%) and normoglycaemic patients (17.0%, P=0.03). Stress MBF was lowest in diabetic patients (1.53±0.52) then prediabetic patients (1.59±0.54) then normoglycaemic patients (1.93±0.62, P< 0.001 for trend) seen in table 1. MPR was not significantly different between groups. During follow up 45 patients suffered at least one MACE event. MACE events by glycaemic status are represented in table 2. On univariate Cox regression analysis, a diagnosis of DM was associated with increased risk of MACE ([HR] 1.95 [1.07-3.55 95% CI]). In diabetic patients, MACE was associated with LVEF, RVEF, rest MBF, MPR, native T1 and silent IHD but stress MBF was not. After stepwise Cox regression only RVEF, rest MBF and silent IHD, but not MPR, were associated with MACE (table 3).
Conclusion:
Diabetic patients with HF and no history or symptoms of IHD had worse outcomes than their non-diabetic counterparts which was associated with silent IHD but not CMD. Silent IHD in diabetic HF patients is an important contributor to adverse cardiovascular outcomes.