Aurangabad [MS], India.

Transcription

1 International Journal of Current Medical And Applied Sciences, 2016, January,9(2), ORIGINAL RESEARCH ARTICLE Study of Diastolic Dysfuntion in Asymptomatic Type-2 Diabetes Mellitus. Aniruddha Londhe 1, Manjiri Naik 2, Vikramaditya Shinde 1, Purvi Patel 1 & Suraj Wyavahare 1 1 Post-Graduate Student, 2 Associate professor, Department of Medicine, MGM Medical College & Hospital Aurangabad [MS], India. Abstract: The chronic metabolic disorder diabetes mellitus is a fast growing global problem with huge social, health, and economic consequences. It is estimated that in 2010 there were globally 285 million people (approximately 6.4% of adult population) suffering from this disease. This study aims at to identify the diastolic dysfunction in type 2 diabetes mellitus patient to recognise the early involvement of heart. Present study revealed that higher percentage of patients with diastolic dysfunction as duration of diabetes increased. Patient receiving OHA were more 128(64%) compared to 44(22%) patients who were on insulin and 28 (14%) patients were on both insulin and OHA. In our studies there is marginal high percentage of diastolic dysfunction in patients who were on insulin and OHA as compared with insulin only. Prevalence of diastolic dysfunction increased gradually with the rise in HbA1c level. The prevalence of left ventricular diastolic dysfunction in asymptomatic type 2 DM without significant coronary artery disease is much higher than previously suspected as evidenced by the results of this study and also of similar other studies. LV diastolic dysfunction is a marker of evolving heart disease among diabetics. LV diastolic dysfunction correlated with duration of diabetes, HbA1c levels and glycemic control which contributes significantly to the morbidity of congestive heart failure in diabetic patients. Early diagnosis and institution of treatment for LVDD in diabetic patients will reduce the morbidity and improve the outcomes by preventing future development of heart failure. Key Words: Diabetic Mellitus, Glycemic, Diastolic Dysfunction, Cardiac Diseases etc. Introduction: The chronic metabolic disorder diabetes mellitus is a fast growing global problem with huge social, health, and economic consequences. It is estimated that in 2010 there were globally 285 million people (approximately 6.4% of adult population) suffering from this disease. This number is estimated to increase to 430 million in the absence of better control or cure. An ageing population and obesity are two main reasons for the increase. Furthermore it has been shown that almost 50% of the putative diabetics are not diagnosed until 10 years after onset of the disease, hence the real prevalence of global diabetes must be astronomically high. Diabetes mellitus is a disease known to mankind for the past 2500 years [1]. Diabetes mellitus is a syndrome characterised by chronic hyperglycemia and disturbances of carbohydrate, fat and protein metabolism associated with absolute or relative deficiency in insulin secretion and/or insulin action, which is modulated by genetic, HLA and environmental factors resulting in micro and macro angiopathy. Address for correspondence: Dr. Aniruddha Londhe, Post-Graduate Student, Department of Medicine, MGM s Medical College & Hospital, Aurangabad [MS], India. anirudhalondhe@yahoo.com How to cite this article: Aniruddha Londhe & Manjiri Naik et al : Study of Diastolic Dysfuntion in Asymptomatic Type-2 Diabetes Mellitus.: International Journal of current Medical and Applied sciences; 2016, 9(2), Access this Article Online Quick Response Code Website: Subject: Medical Sciences IJCMAAS,E-ISSN: ,P-ISSN: Page 101

2 Aniruddha Londhe, Manjiri Naik, Vikramaditya Shinde, Purvi Patel & Suraj Wyavahare It often runs in families. It is associated with decrease in insulin production or utilization, resulting in body s inability to utilize nutrients appropriately. Various genetic and environmental factors influence the aetiology and prognosis of diabetes. Important differences in the types and frequency of Diabetes mellitus and its complications have been reported between countries as well as ethnic and cultural groups. People with diabetes are 2-4 times more likely to have coronary heart disease and stroke than people without. Diabetes mellitus was formerly considered a disease of affluent. It has now become apparent that increase in Diabetes mellitus is due to demographic changes, cultural transition and population ageing, urbanization, increased consumption of refined foods, westernization, sedentary habits and over nutrition [2,3]. It is a silent killer disease. The World Health Organisation estimates that the disease burden of Diabetes mellitus world over would be more than 500 million in 21 st century. Indians are genetically more susceptible to Diabetes mellitus compared to other races. Indians settled abroad also show increased prevalence to Diabetes mellitus indicating that environmental factors also play a role in incidence of diabetes. India will have the largest number of diabetic subjects in the world by 2025 and one out of 5 diabetic subjects in the world will be an Indian. India is going to be the Diabetic capital of the world [2,3]. WHO has estimated that the number is likely to be 5.72 crore by The rapid increase in population, increased longevity and high ethnic susceptibility to diabetes, coupled with rapid urbanization and changes from traditional lifestyles will most likely trigger a Diabetes mellitus epidemic2,3. Subclinical abnormalities of left ventricular function are recognized in both Type 1 and Type 2 diabetes mellitus. Studies using Doppler echocardiography have confirmed the findings of abnormal diastolic function as an early indicator of cardiac involvement in asymptomatic patients with Type 1 or Type 2 diabetes mellitus. Diabetic subjects have been reported to develop congestive heart failure in the absence of coronary heart diseases, hypertension or any known structural heart disease [4]. The term diabetic cardiomyopathy has been introduced for this condition. It has been suggested that microangiopathic lesions of the myocardium, altered composition and fibrosis of myocardial interstitium and accumulation of lipids in myocardial cells are involved in pathogenesis of diabetic cardiomyopathy [5,6]. Diastolic dysfunction refers to a condition in which abnormalities in mechanical function are present during diastole. Abnormalities in diastolic function can occur in the presence or absence of a clinical syndrome of heart failure and with normal or abnormal systolic function. Therefore, whereas diastolic dysfunction describes an abnormal mechanical property, diastolic heart failure describes a clinical syndrome. Conceptually, diastole encompasses the time period during which the myocardium loses its ability to generate force and shorten and returns to an unstressed length and force. By extension, diastolic dysfunction occurs when these processes are prolonged, slowed, or incomplete. Whether this time period is defined by the classic concepts of Wiggers or the constructs of Brutsaert [7], the measurements that reflect changes in this normal function generally depend on the onset, rate, and extent of ventricular pressure decline and filling and the relationship between pressure and volume or stress and strain during diastole. Moreover, if diastolic function is truly normal, these measurements must remain normal both at rest and during the stress of a variable heart rate, stroke volume, end-diastolic volume, and blood pressure. This study aims at to identify the diastolic dysfunction in type 2 diabetes mellitus patient to recognise the early involvement of heart. Methods and Materials: A total of 200 cases of type 2 diabetes mellitus with prior informed consent who clinically had no symptoms of cardiovascular involvement and blood pressure <130/80mm of Hg, with normal ECG were included in the study.. The study group included both outpatients as well as in-patients. All these patients were evaluated for diastolic dysfunction. The study protocol was approved by the Medical Ethics Committee For Research on Human Subjects of the MGM Medical College and Hospital Aurangabad [MS], India. Type of Study - Cross Sectional & Observational Study. Number of cases for study- 200 Study centre- MGM medical college and hospital, Aurangabad. Duration of study- June 2013 to December Inclusion Criteria: All cases of type II diabetes Mellitus as per American Diabetic Association (ADA 2013) criteria without cardiac manifestations were taken for the study. Exclusion Criteria - All hypertensive patients with or without medication were excluded from the study All the cases ischemic heart disease on treatment was excluded. All the cases of valvular heart diseases were excluded. All cases of chronic kidney diseases were excluded. Logic 2016, IJCMAAS, E-ISSN: ,P-ISSN: Page 102

3 Logic 2016, IJCMAAS, E-ISSN: ,P-ISSN: All Pregnant cases were excluded from the study. Any other disease/disorders interfering with the cardiac function were excluded from the study. All cases are subjected to methods & examination with special attention to following parameters as investigations. 1.Fasting and post meal blood sugar levels 2. Renal function tests, including sr. electrolytes 3. Glycosylated hemoglobin (HbAlc) 4. Fasting lipid profile 5. ECG in all 12 leads 6. TMT 7. Chest X-ray PA view 8. 2D-Echocardiography Observations and Results: Table 1: Distribution of patients according to gender and its correlation with diastolic dysfunction: Gender Diastolic dysfunction Total Present Absent Male 32 (40.0%) 48 (60.0%) 80 (40.0%) Female 64 (53.0%) 56 (47.0%) 120 (60.0%) Total 96 (48.0%) 104(52.0%) 200 (100%) [Pearson = 2.91, df = 1, p = 0.08 (NS)] Present study consisted of 200 patients with type 2 DM, among whom 120(60%) were females and 80 (40%) males. Diastolic dysfunction was present in 96 (48%) of the cases among them, 32 were males, 64 were females. Though statistically not significant, diastolic dysfunction was more prevalent in females. Table 2: Distribution of patients according to age groups and its correlation with diastolic dysfunction. Diastolic dysfunction Total Age wise distribution Present Absent N=96 % N=104 % N=200 % % % % % % % % % % % % % 70-above % 0 00% % [Pearson = 40.0, df = 4, p = (VHS)] Out of 96(48%) with Diastolic dysfunction maximum prevalence was found in years age group. In 28 patients of age group years 4(14.28%) patients had diastolic dysfunction. In 48 patients of age group years 27 (57.14%) has diastolic dysfunction. Whereas in 20 patients of age-group 70 years & above all the 20(100%) had diastolic dysfunction. There was a linear increase in the prevalence of diastolic dysfunction with the increasing age. The age-group of patients and outcome of Diastolic dysfunction was statistically significantly associated [p=0.000]. Table 3 : Association between duration of diabetes & diastolic dysfunction Duration in Diastolic dysfunction Total year Present Absent N % N % N % % % % > % Total [Pearson = 22.19, df = 3, p = < (VHS)] Comparing with duration of diabetes, we had 84(42%) patients with 0-5 year duration of diabetes and 80(40%) patients with 6-10 years duration of diabetes. Out of 96 patients of Diastolic dysfunction the maximum International Journal of Current Medical And Applied Sciences [IJCMAAS], Volume : 9, Issue: 2.

4 Aniruddha Londhe, Manjiri Naik, Vikramaditya Shinde, Purvi Patel & Suraj Wyavahare prevalence was noted in duration of Diabetes 6-10 years i.e.41.67%. Statistically it was significant as we had higher percentage of patients with diastolic dysfunction as duration of diabetes increased. Table 4 : Association between type of treatment and diastolic dysfunction. Diastolic Dysfunction Type of Present Absent Total Treatment N % N % N % OHA % % Insulin % % Both % % Total % % % [Pearson = 2.62, df = 2, p = 0.27 (NS)] Patients receiving OHAS were more 128 (64%) compared to 44 (22%) patients who were on insulin. And 28(14%) patients were on both insulin and OHAs. The patients who on Insulin & OHA had more prevalence of Diastolic Dysfunction i.e %.where as Type of Treatment & outcome of Diastolic Dysfunction were not statistically associated. Table 5: Association between HbA1C level and Diastolic Dysfunction Diastolic Dysfunction HbA1C level Present Absent Total N % N % N % % % % % % % % % > % % % Total % % % [Pearson = 49.09, df = 3, p = < (VHS)] 100(50%) subjects had HbA1c >8 %which indicated poor glycemic control. Prevalence of diastolic dysfunction increased gradually with the rise in HbA1c levels and it was statistically significant as shown in (Table 5). Diastolic dysfunction was present in 24 patients out of 100 with HbA1c between <8%.. In patients with HbA1c >10 % out of 28 patients 24 had diastolic dysfunction. There were significant changes in E, A and E/A ratio in patients who had diastolic dysfunction. Left atrial size was higher in patients who had diastolic dysfunction. The mean LA size was ± 0.14 in patients who did not have diastolic dysfunction and it was 3.40 ± 0.25 in patients who had diastolic dysfunction. Discussion: Epidemiological data indicate that there is a significant relationship between diabetes and cardiovascular disease. Diabetic cardiomyopathy has been proposed as an independent cardiovascular disease and left ventricular diastolic dysfunction may represent the first stage of diabetic cardiomyopathy. Various studies have shown the evidence of left ventricular diastolic dysfunction in normotensive, type 2 diabetic patients. However, the exact causes and mechanisms remain unclear. Impairment of diastolic function of left ventricle are more common than systolic dysfunction. Hence it has to be evaluated in early stage of disease. In this study we evaluated left ventricular function by m-mode, 2-D echo and colour Doppler studies in Type 2 diabetes patients. Two hundred patients who are asymptomatic type 2 diabetes were selected for the present study from M.G.M. Medical College, Aurangabad by Simple Random Sampling method during the study period of June 2013 to December All patients were evaluated for the left ventricular diastolic dysfunction. Age of the patients: In the present study age of the patients ranged from 30 year and onwards with Majority of the patients are belonged to 4th-6th decades. Mean age of the present Study was 46.7 and SD 10.4 comparable to that of Shrestha NR et al. [8], Fawad Ahmad Randhawa et al.[9], Rajesh Rajput et al [10], and Virendra Patil et al [11] as included only Type 2 Diabetes mellitus the mean age was almost identical. In present study, found that in 50-59years age group diastolic dysfunction was About 57.14%, which was comparable with Fawad et al [9] in which there was 73% prevalence of diastolic dysfunction in age group of years. In age group above 70 years each Logic 2016, IJCMAAS, E-ISSN: ,P-ISSN: Page 104

5 Logic 2016, IJCMAAS, E-ISSN: ,P-ISSN: patient had diastolic dysfunction (100%) in present study. Sex Incidence: It can be observed that there was female predominance in the present study. In present study it was observed that percentage of diastolic dysfunction among both gender had significant difference with female (53%) predomince as compared with male (40%). This could be due to hormonal changes that accompany after menopause. This was comparable to that of Patil MB et al [12] with 68.18% of female patients having diastolic dysfunction. Duration of Diabetes: In our study most of the patients had duration of diabetes less than 10 years. This was because, as the duration of diabetes increased, other associated comorbid diseases like hypertension, IHD, would also appear and hence could not be included in our study. So the patients with duration of diabetes more than 15 years and age above 70 years were less. It was observed that patients had 100% diastolic dysfunction with duration of diabetes more than 15 years & 71.42% in patients with years of diabetic duration. This is comparable to Virendra Patil et al [11] in which there was 75.51% diastolic dysfunction in patients with years of diabetes duration. Treatment Profile: When the treatment profile was evaluated most of the patients were on OHA / OHA with insulin, most of the subjects had poor glycemic control, reasons are multifactorial Viz., poor compliance of the patient with reference to treatment, lifestyle modifications, inadequate doses, poor regular checkup. In our study there was marginal high percentage of diastolic dysfunction in patients who were on both insulin and OHA (57.14%) as compared with insulin only (54.54%) and significantly higher than patients who were on OHA only (43.75%). This is comparable to that of Madhumathi R et al [13], found that around 57% patients had diastolic dysfunction who were on both insulin and OHA. Glycemic control: In present study showed that 50% subjects had HbA1c >8 %which indicated poor glycemic control. Prevalence of diastolic dysfunction increased gradually with the rise in HbA1c levels. It was showed that 72% patients had diastolic dysfunction with HbA1c level >8% which significantly comparable with Virendra Patil et al [11] study showed that 81.57% of diastolic dysfunction in patients with HbA1c level above 7.5%. Left ventricular diastolic dysfunction (LVDD) was found in 96(48%) of patients. This prevalence of diastolic dysfunction was almost comparable with other studies as shown in below table. Table 6 : Comparison of Diastolic dysfunction with other studies Percentage of Studies Diastolic dysfunction Virendra Patil et al [11] 54.33% Fawad et al [10] 48.0% Paul Poirier et al [14] 60.0% Faden G et al [15] 64.0% Markuszewski et al [16] 43.0% Present study 48.0% Conclusion: The prevalence of left ventricular diastolic dysfunction in asymptomatic type 2 Diabetic Mellitus without significant coronary artery disease is much higher than previously suspected as evidenced by the results of this study and also of similar other studies. LV diastolic dysfunction is a marker of evolving heart disease among diabetics. LV diastolic dysfunction correlated with duration of diabetes, HbA1c levels and glycemic control which contributes significantly to the morbidity of congestive heart failure in diabetic patients. Echocardiography with measurements of diastolic functional parameters appears to be a sensitive noninvasive method for evaluating the manifestation. Early diagnosis and institution of treatment for LVDD in diabetic patients will reduce the morbidity and improve the outcomes by preventing future development of heart failure. References: 1. Nagaraju N And Rao K N. Folk ; Medicine for Diabetes from Rayalaseema of Andhra Pradesh. Ancient Science of Life, 1989: 9(1): Park K. Diabetes mellitus; Epidemology of chronic non- communicable diseases and condition. Chap 6. Parks Textbok of preventive and Social Medicine. (17th edition). India: Banarsidas Bhanot 2002; Munichoodappa C. Epidemiology and burden of type 2 diabetes mellitus. In: Type diabetes The Indian scenario, Jayaram BM (ed). Bangalore: Microlabs Ltd 2008; Kannel WB, Hjortland M, Castelli WP. Role of diabetes in congestive heart failure. The Framingham Study. American Journal of Cardiology. 1974: 4(3): Ramachandran A, Jali MV, Mohan V, Snehlatha C, Vishwanathan M. High prevalence of diabetes in urban population in South India. BMJ 1988; 297: Ramachandran A, Snehlatha C, Dharamraj D, Vishwanathan M. Prevalence of glucose intolerance in Asian Indians, urbanrural difference and significance of upper body adiposity. Diabetes Care. 1992:15(10): International Journal of Current Medical And Applied Sciences [IJCMAAS], Volume : 9, Issue: 2.

6 Aniruddha Londhe, Manjiri Naik, Vikramaditya Shinde, Purvi Patel & Suraj Wyavahare 7. Brutsaert DL, Sys SU. Diastolic dysfunction in heart failure. J Card Fail. 1997: 3(3): Shrestha NR, Sharma SK, Karki P, Shrestha NK, Acharya P. Echocardiographic Evaluation of Diastolic Function in Asymptomatic Type 2 Diabetes. J Nepal Med Assoc 2009: 48(173): Randhawa FA, Malik TH, Shaista N, Faisal M. Frequency od diastolic dysfunction in asymptomatic normotensive type-2 diabetes patients. J Ayub Med Coll Abbottabad. 2014:26(1): Rajput R, Jagdish, Siwach SB, Rattan A. Echocardiographic and Doppler assessment of cardiac functions in patients of non-insulin dependent diabetes mellitus. JIACM 2002: 3(2): Patil VC, Patil HV, Shah KB, Vasani JD, Shetty P. Diastolic dysfunction in asymptomatic type 2 diabetes mellitus with normal systolic function. Journal of Cardiovascular Disease Research : 2(4): Patil MB, Burji NP. Echocardiographic evaluation of diastolic dysfunction in asymptomatic type 2 diabetes mellitus. J Assoc Physicians India. 2012: 60: Madhumati R, Gowdaiah PK, Dudhwewala A, Chaithra AN, Dande T. Echocardiographic evaluation of diastolic dysfunction in asymptomatic type 2 diabetes mellitus. Journal of Evolution of Medical and Dental Sciences. 2014: 3(1): Poirier P, Bogaty P, Garneau C, Marois L, Dumesnil JG. Diastolic dysfunction in normotensive men with well controlled type 2 diabetes mellitus. Diabetes Care. 2001: 24(1): Faden G, Faganello G, De Feo S, Berlinghieri N, Tarantini L, Di Lenarda A, et al. The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: Data from the SHORTWAVE study. Diabetes Res Clin Pract. 2013:101(3): Markuszewski L, Grycewicz T, Pietruszynski R, Michalkiewicz D, Roszczyk N.Glycosylated hemoglobin and left ventricular diastolic dysfunction in patients with type 2 diabetes mellitus. Pol Merkur Lekarski. 2006: 21(121): Conflict of interest: None declared No source of funding. Logic 2016, IJCMAAS, E-ISSN: ,P-ISSN: Page 106