Clinical and echocardiographic characteristics and cardiovascular outcomes according to diabetes status in a large general population sample
Authors: Lassen M C H , Skaarup K G , Johansen N D , Vaduganathan M , Qasim A , Jensen G B , Schnohr P , Jensen M T , Mogelvang R , Biering-Sorensen T 
Published: November 2023

Abstract

Background
The recently introduced Universal Definition of Heart Failure (HF)(1) considers abnormal cardiac structure or function in the absence of signs/symptoms of HF to be "pre-HF" (stage B), yet lacks clear direction regarding the specific structural abnormalities that may most strongly forecast incident HF and cardiovascular death (CV death). Clarifying optimal imaging-based screening has important population-level implications, especially for at-risk cohorts like those with diabetes mellitus (DM).

Purpose
We aimed to describe the clinical and echocardiographic characteristics of individuals with DM compared to individuals without and to assess whether DM status impacted the prognostic value of echocardiographic parameters in relation to HF and CV death.

Methods
All participants from a large, prospective cohort study of the general population (inclusion period: 2011-2015) had a comprehensive echocardiographic examination performed and analyzed according to current guidelines. Additionally, all participants had a general physical exam performed and answered an extensive questionnaire. The outcome was a composite of HF and CV death during follow-up. DM was included in the models to test for interactions between echocardiographic parameters and the composite outcome.

Results
A total of 4,225 participants were included in the present study. Among these, 191 (4.5%) had DM. The mean age of the study population was 56.3 years and 57.0% were female. Risk factors associated with cardiovascular disease and impaired echocardiographic parameters (Table 1) were more frequent in individuals with DM compared to those without. During follow-up (median 3.5 years, IQR: 2.6, 4.3) a total of 126 (3.0%) met the composite outcome. The incidence rate was higher in participants with DM than in participants without (8.0 events per 10,000 person-years vs. 2.1 events per 10,000 person-years, p&lt;0.001). In a multivariable model adjusted for baseline demographic, clinical, and echocardiographic parameters, DM was associated with an increased risk of the composite outcome (HR: 2.1, 95%CI: 1.1-4.0), p = 0.028) when compared with participants without DM. All assessed echocardiographic parameters had the same prognostic value regardless of DM status except for E/e’ which seemed to be less associated with the composite outcome in participants with DM (with DM: HR: 1.03, 95%CI: 0.85-1.24, p = 0.78, per 1 unit increase of E/e’) (without DM: HR: 1.32, 95%CI: 1.25-1.39, p&lt;0.001, per 1 unit increase of E/e’) (p for interaction = 0.011) (Figure 1).

Conclusion
In the general population, several echocardiographic structural and functional abnormalities identified those with pre-HF and DM at high risk for progression to incident HF and cardiovascular death. The cost-effectiveness and feasibility of point-of-care echocardiography for screening should be assessed, especially in high-risk individuals with DM.Table 1Figure 1