Feature Article

Diabetic cardiomyopathy: mechanisms, screening and treatment imperatives

FARRAH OTHMAN, MAXWELL FULTON, Sean Lal

Figures

© pearl photopix/shutterstock models used for illustrative  purposes only
© pearl photopix/shutterstock models used for illustrative purposes only

Abstract

Diabetic cardiomyopathy (DCM) refers to structural and functional changes in the heart as a consequence of diabetes that may be independent of, or in combination with, coronary disease (microvascular, macrovascular or both). As DCM tends to be asymptomatic, it is important that GPs are vigilant in screening patients early for DCM and preventing progression.

Key Points

  • Diabetic cardiomyopathy (DCM) has a unique pathogenesis and clinical spectrum.
  • People with diabetes, especially women, have an increased risk of heart failure (HF), independent of traditional cardiac risk factors.
  • The initial cellular and structural changes in DCM, such as cardiac fibrosis, usually precede the onset of symptoms.
  • Initially, there may only be left ventricular hypertrophy before onset of left ventricular diastolic dysfunction and, finally, overt systolic dysfunction.
  • People with diabetes and HF have a higher mortality rate. Overt systolic dysfunction confers a poor prognosis.
  • High-risk patients should be identified and screened with ECG and echocardiography.
  • Detecting changes in strain parameters on echocardiography is pivotal in making a prompt diagnosis and early referral to a cardiologist.
  • Cardiac MRI is emerging as a useful and sensitive tool for early identification of structural changes associated with DCM, including signs that cannot be identified on an echocardiogram; however, access in the community is limited.
  • Aggressive treatment of modifiable cardiac risk factors is imperative to prevent progression of HF.
  • Good glycaemic control is important; however, intensive control (glycated haemoglobin level below 6%) is not beneficial and may cause harm.
  • Treatment with SGLT-2 inhibitors is showing promise in targeting the metabolic changes and reduces HF hospitalisations in people with diabetes, beyond the effect on blood glucose levels.
  • An integrated approach involving a heart failure care team, diabetic educator and cardiologist is pivotal.

Figures

© pearl photopix/shutterstock models used for illustrative  purposes only
© pearl photopix/shutterstock models used for illustrative purposes only