Screening for Heart Disease in Diabetic Subjects: Methods

Authors and Disclosures

Methods
Patient Selection We studied 101 unselected asymptomatic patients with diabetes mellitus. These patients were recruited prospectively from the ambulatory Diabetes Clinic at Princess Alexandra Hospital, Brisbane, Australia. Patients were included if they had no history of heart disease or complaints related to cardiac disease and no history of CAD, moderate to severe valvular disease, atrial fibrillation, or other severe arrhythmias and congenital heart disease. Blood for BNP, glucose, hemoglobin A1C, and lipid profile was drawn from every subject after fasting at least for 8 hours and before oral antidiabetic drugs or insulin and treadmill exercise testing. Resting Echocardiography All patients underwent echocardiography for research purposes. Subjects were examined in the left lateral decubitus position using a standard commercial ultrasound machine (Vivid 7; GE-Vingmed, Horten, Norway) with a 2.5-MHz phased array probe. Three apical views (apical 4-chamber, 2-chamber, and long-axis views) were acquired using standard harmonic imaging. Mitral and pulmonary inflow velocities were recorded by using conventional pulsed-wave Doppler echocardiography. Left ventricular diameters and wall thicknesses were measured from 2-dimensional targeted M-mode echocardiography. Left ventricular mass was determined by Devereux's formula.[8] Left ventricular hypertrophy was defined as LV mass index (g/m2) greater than 131 g/m2 in men and greater than 100 g/m2 in women.[9] Resting LV end-diastolic, end-systolic volumes and ejection fraction were computed using a modified Simpson's biplane method. Regional wall motion analysis was scored as normal, mildly hypokinetic, severely hypokinetic, and akinetic by 2 observers blinded to the patient's clinical data. Infarction was identified by resting wall motion abnormalities. Patients with LV ejection fraction < 50% or evidence of infarction were excluded. Stress Testing Exercise echocardiography was performed in all patients using a standard symptom-limited exercise protocol, selected in accordance with the age and fitness of the subject. Blood pressure and cardiac status by 12-lead electrocardiogram were monitored during the exercise test. Regional wall motion was compared before and after stress, and patients with ischemia were identified by inducible wall motion abnormalities. Tissue Doppler Acquisition and Analysis The same echocardiograph machine was used to acquire color tissue Doppler data using a high-frequency acquisition. The imaging angle was adjusted to ensure a parallel alignment of the beam with the myocardial segment of interest.

Using standard commercial software (Echopac PC, GE-Vingmed), resting basal segmental myocardial peak systolic velocity (Sm) and diastolic velocity (Em) and strain of each wall in the 3 apical views were measured from tissue Doppler imaging data by using a sample volume (5 10 mm2) and averaged for each patient. Strain curves were attempted in each segment of the wall by sampling in the mid-myocardial layer, and data were excluded if we were unable to obtain a smooth strain curve or the angle between the scan-line and wall was > 20. Peak strain was defined as the greatest value on the strain curve. Significant subclinical diabetic heart disease was defined if an individual patient's Sm or Em was less than the mean value minus one SD obtained from age- and sex-specific normal ranges10 (Figures 1 and 2).

Figure 1.

This figure shows myocardial peak velocities (systolic velocity of 6.5 cm/s and diastolic velocity of 6.1 cm/s) and peak strain (26%) obtained from a diabetic patient (male, 40 years old) with normal LV function.

Figure 2. This figure shows myocardial peak velocities (systolic velocity of 2.9 cm/s and diastolic velocity of 2.7 cm/s) and peak strain (19%) obtained from a diabetic patient (female, 58 years old). Despite the presence of apparently normal LV function, these findings are grossly abnormal and signify subclinical heart disease. Brain natriuretic peptide level was normal. BNP Assay Brain natriuretic peptide was measured within 1 hour after blood collection using the Triage BNP assay (Biosite, San Diego, Calif).[11] Because age and sex have been shown to influence circulating BNP levels in subjects without cardiovascular disease,[12] age and sex should be taken into account to evaluate subjects with possible cardiovascular disease. Thus, in this study, BNP was classified as either normal or abnormal according to age and sex for each patient.[12] Interobserver and Intraobserver Variability Variability in the measurement of Sm, Em, and peak strain using the same acquired imaging data were evaluated in 13 patients randomly selected from patients without LVH or CAD by 2 independent observers for interobserver and intraobserver variability. To determine reproducibility, the same observer who was blinded to the former results measured Sm, Em, and peak strain for each of the selected patients again at a separate time (at least 2 weeks). To test interobserver variability, another observer who was unaware of patient identity and first observer's results analyzed the same patients' data in the same way. Statistical Analysis Data were analyzed using standard statistical software (SPSS, Chicago, Ill). Values were expressed as a mean SD; normally, distributed data were compared using Student independent-samples t text, and the Mann-Whitney test was used to compare the difference between data without normal distribution. A P value < .05 was considered statistically significant.