# Presentation: 155424

## Cardiac Structure and Function, Diabetes and Cardiovascular Disease Risk: The Strong Heart Study

- Richard B. Devereux, M.D.
- Weill Medical College of Cornell University

## Diabetes Prevalence Differs by Ethnicity

- Diabetes Prevalence (%)

**    ****p<0.001**

- Galderisi et al.: Am J Cardiol 1991; Palmieri et al.: Circulation 2001;103:102-109;  Devereux et al.: Circulation 2000;101:2271-2276; Carter et al.: *Diabetologia* 2006;49:29-35. .

**p<0.001**

**p<0.001**

- Mean BMI        ~27             ~32           ~32.5          ~31.5         ~27.5

## The Strong Heart Study: A Partnership of Investigators with American Indian Communities 

- NHLBI funded 1988-2010...

- The Strong Heart Study: A Partnership of Investigators with American Indian Communities

## Pathways to Cardiovascular Morbid Events

**Pathways to Cardiovascular Morbid Events**

- Devereux and Alderman: *Circulation* 1993;88:1444-1455.

**LV Dysfunction**

## LEFT VENTRICULAR HYPERTROPHY: ANATOMY

**LEFT VENTRICULAR HYPERTROPHY: ANATOMY**

## LEFT VENTRICULAR HYPERTROPHY: ECHO

**LEFT VENTRICULAR**** ****HYPERTROPHY: ECHO**

## Echo LVH Predicts Death with and Without CAD

**In catheterized black patients with or without angiographic CAD, echo LVH predicts all-cause mortality, more strongly than EF or # of diseased vessels**

- Ghali et al: Ann Intern Med 1992; Liao et al: JAMA 1995

## 12-Year CV Event Rate with Diabetes vs. Normal or Impaired Fasting Glucose:The Strong Heart Study

- CV Events (%)

- 60
- 40
- 20
-   0

- Diabetes

- NFG & IFG

- Devereux et al.: unpublished data 3/2006.

## Do Measures of Preclinical CV Disease Stratify Risk in Diabetes?  I: Left Ventricular Hypertrophy

## LV Mass in Glucose Tolerant vs Diabetic American Indians: The Strong Heart Study

- P<0.001

- P<0.001

- P<0.001

- Devereux et al: Circulation 2000; 101:2271-2276.

*P, adjusted for age,*
*gender, height, weight, SBP, *
*HTN Rx and center.*

## Prevalence of LVH in SHS Participants Grouped by Diabetes & Hypertension Status

- All p<0.001

- LVH Prevalence (%)

- From Bella et al: Am J Cardiol 2001;87:1260-1265.

- P, adjusted for
- age, gender,
- height, weight,
- SBP, HTN Rx
- and center.

## Association of LV Hypertrophy with CV Events in Diabetic American Indians: The Strong Heart Study

- Proportion Suffering CV Events

- P<0.0001, adjusted
- for age, gender, BP,
- BMI, LDL, HDL,
- smoking and plasma
- creatinine.

- Hazard ratio =
- 1.58 (95% CI =
- 1.27-1.97)

- Devereux et al.: unpublished data 3/2006.

## Association of LV Hypertrophy with CV Death in Diabetic American Indians: The Strong Heart Study

- Proportion Suffering CV Events

- P<0.0001, adjusted
- for age, gender, BP,
- BMI, LDL, HDL,
- smoking and plasma
- creatinine.

- Hazard ratio =
- 1.90 (95% CI =
- 1.33-2.71)

- Devereux et al.: unpublished data 3/2006.

- Proportion Suffering CV Death

- Days after Echocardiogram

## Do Measures of Preclinical CV Disease Stratify Risk in Diabetes?  II: LV Systolic Function

## Fractional Shortening in SHS Participants Grouped by Diabetes & Hypertension Status

- P<.001

- From Bella et al: Am J Cardiol 2001;87:1260-1265.

- Fractional Shortening (%)

- NS

- NS

- P, adjusted for age,
- gender, height,
-  weight, SBP,
- HTN Rx and center.

## Left Ventricular Contractility in SHS Participants Grouped by Diabetes & Hypertension Status

- P<.01

- P<.001

- Stress-Corrected MWS (%)

- From Bella et al: Am J Cardiol 2001;87:1260-1265.

- P, adjusted for age,
- gender, height,
- weight, SBP,
- HTN Rx and center.

## Stress-Corrected Midwall Shortening & CV  Events in Diabetes: The Strong Heart Study

- P=0.002, adjusted
- For age, gender,
- BP, BMI, LDL, HDL,
- smoking and urine
- albumin/creatinine.
- OR = 1.51, 95% CI =
- 1.16-1.97

## Stress-Corrected Midwall Shortening & CV  Death in Diabetes: The Strong Heart Study

- P=0.008, adjusted
- For age, gender,
- BP, BMI, LDL, HDL,
- smoking and urine
- albumin/creatinine.
- OR = 1.75, 95% CI =
- 1.15-2.52

## Do Measures of Preclinical CV Disease Stratify Risk in Diabetes?  III: LV Diastolic Filling 

## Mitral E/A Ratio in SHS Participants Grouped by Diabetes & Hypertension Status

- From Liu et al: J Am Coll Cardiol 2001;37:1943-1949.

- P<0.001 adjusted for covariates*

- *P, adjusted for age, gender, heart rate,
- SBP and center.

## Diastolic Filling Pattern & Cardiovascular Death in Diabetes: The Strong Heart Study

- P<0.011, adjusted
- For age, gender, BP,
- BMI, LDL, HDL &
- smoking.
- Restrictive Pattern:
- OR = 2.37, 95% CI =
- 1.22-4.63

- Devereux et al.:
- 3/2006

- Proportion Suffering CV Death

## Do Measures of Preclinical CV Disease Stratify Risk in Diabetes?  IV: Arterial Hypertrophy & Plaque

## Noninvasively Measurable Manifestations 

- Noninvasively Measurable Manifestations
- of Preclinical Cardiovascular Disease

- Devereux and Alderman: Circulation 1993;88:1444-1455.

## Prevalence of Discrete Carotid Plaque in IGT & Diabetes: The Strong Heart Study

- Roman et al: JACC 1999;33:274A.

- P<0.001, adjusted
- for age, gender, BP, smoking &
- cholesterol

**Plaque Prevalence (%)**

## Discrete Carotid Plaque & Cardiovascular Death in Diabetes: The Strong Heart Study

- P<0.006, adjusted
- For age, gender, BP,
- BMI, LDL, HDL &
- smoking.
- Restrictive Pattern:
- OR = 3.71, 95% CI =
- 1.46-9.39

- Devereux et al.:
- 3/2006

- Proportion Suffering CV Death

## Adverse Cardiovascular Effects of Diabetes: Conclusions

- As the US population becomes more obese & older, diabetes is becoming  ‘epidemic’
- In SHS participants, diabetes is associated, independent of covariates & CHD manifested clinically or by echo or ECG, with:
- LV hypertrophy & dysfunction, impaired LV filling and systemic atherosclerosis
- In diabetic adults, these abnormalities independently predict CV events and death, with HRs 1.5 to 3.7.
- Thus, assessment of preclinical CV disease improves prediction of risk in diabetic adults and may identify individuals who will especially benefit from therapy that is more intensive or targeted to reversal of cardiac abnormalities.

## {

**Pathways to Cardiovascular Events in Diabetes: Lessons from the Strong Heart Study**

- Adapted from Devereux and Alderman: *Circulation* 1993;88:1444-1455.

**LV Dysfunction**

**CV Events**
**CV Death**

## {

**Prevention of Cardiovascular Events in Diabetes: Future Challenges for SANDS and Beyond**

- Adapted from Devereux and Alderman: *Circulation* 1993;88:1444-1455.

**LV Dysfunction**

**CV Events**
**CV Death**

**Optimal control of glycemia, BP, lipids, regimens**
**optimized to reverse LVH, dysfunction & plaque**