clinicAl cArdiology: originAl Article
Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus Marcelo Utrera-Lagunas MD1, Arturo Orea-Tejeda MD1, Lilia Castillo-Martínez PhD1, Karla Balderas-Muñoz MD1, Candace Keirns-Davis MD2, Sarahi Espinoza-Rosas BSc1, Néstor Alonso Sánchez-Ortíz BSc1, Gabriela Olvera-Mayorga BSc1 M Utrera-Lagunas, A Orea-Tejeda, L Castillo-Martínez, et al. Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus. Exp Clin Cardiol 2013;18(1):e44-e46. BACKGROUND: Diabetes is a major risk factor for heart failure (HF), although the pathophysiological processes have not been clarified. OBjECTivE: To determine the prevalence of HF and of abnormal myocardial perfusion in diabetic patients evaluated using technetium (99m) sestamibi single-photon emission computed tomography. METHODS: An observational cross-sectional study was conducted that included patients with type 2 diabetes mellitus who underwent echocardiography to diagnose HF and a pharmacological stress test with intravenous dipyridamole to examine cardiac scintigraphic perfusion abnormalities. Clinical and biochemical data were also collected. RESULTS: Of the 160 diabetic patients included, 92 (57.6%) were in HF and 68 (42.5%) were not. When patients were stratified according to the
T
he prevalence of diabetes has increased. It is believed that in 2000, there were 3.5 million individuals 65 years of age and older who were affected, and this number was projected to have increased to five million by the end of 2010 (1). These patients are more likely to develop heart failure (HF) compared with the general population, and the RR is particularly marked in younger individuals (2). Thus, diabetes has been recognized as a major risk factor for HF according to data published in epidemiological studies. The two most common risk factors for the development of HF in diabetic patients are hypertension and coronary artery disease (CAD) (3). However, the diagnosis of CAD in the studies reported in the literature is based on clinical information from medical records and electrocardiographic findings (4-6). The pathophysiological process has not been adequately explained, especially in the absence of obstructive epicardial coronary artery lesions. In such cases, an evaluation of myocardial perfusion may be a more effective method of diagnosing myocardial ischemia than coronary angiography. Single-photon emission computed tomography (SPECT) has recently emerged with the expectation that it will emulate the success of positron emission tomography-computed tomography as a hybrid imaging modality. Proponents of SPECT are confident that the addition of computed tomography will lead to a renaissance for SPECT in nuclear cardiology and in other functional studies, and revitalize traditional nuclear medicine (7). It has become accepted as the most accurate method for assessing myocardial viability in patients with CAD and impaired left ventricular function (8). The objective of the present study was to determine the prevalence of HF in patients with type 2 diabetes mellitus and its relationship with ischemic heart disease identified by abnormal perfusion on technetium (99m) sestamibi SPECT in patients who demonstrate no visible obstructive coronary lesions in angiographic evaluations.
METHODS
The present observational, cross-sectional study included patients 18 years of age or older with type 2 diabetes who attended the Internal Medicine Service at Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” (INNCMSZ, Mexico) between February 2011 and January 2012, and agreed to participate.
presence of abnormal myocardial perfusion, those with abnormal perfusion had a higher prevalence of HF (93%) than those with normal perfusion (44.4%) (P12 mm, a posterior wall thickness >12 mm and a characteristic pattern of transmitral Doppler flow (slow, inverted, pseudonormal or restrictive) (9). To evaluate the presence of ischemic heart disease, all patients underwent a pharmacological stress test induced with intravenous dipyridamole infusion at a dose of 0.14 mg/kg weight over 4 min. A saline solution of sestamibi Tc99m (25 μCi [927 MBq]) was administered intravenously during the rest period. In the rest-stress protocol, the patients consumed a fat-rich meal to accelerate hepatobiliary excretion before data acquisition. The images were taken 40 min after sestamibi administration and were compared with the images obtained at rest. The images at rest and during stress were obtained using a Siemens Multispect 2HD/HD gamma camera (Siemens, USA) with two rectangular detectors with 59 photomultiplier tubes each, a Gantry rotation system and a high-resolution collimator of parallel holes. Images were obtained over an anterior arc of 180° at intervals of 6° per step, and 40 s of acquisition beginning 40 min after the administration of the tracer. Evaluation and interpretation were performed according to American Society of Nuclear Cardiology recommendations by two experts in nuclear medicine and nuclear cardiology who were blinded to the clinical characteristics of the patients.
1HF
Clinic, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, 2Massachusetts General Hospital, Boston, Massachsetts, USA. Correspondence: Dr Lilia Castillo-Martínez, HF Clinic INCMNSZ, Providencia 1218-A Int. 402, Colonia del Valle Delegación Benito Juárez 03100, México, DF México. Telephone/fax 5255-55-13-93-84, e-mail [email protected]
e44
©2013 Pulsus Group Inc. All rights reserved
Exp Clin Cardiol Vol 18 No 1 2013
Abnormal perfusion heart failure risk in diabetes
TAble 1 Comparison of clinical and biochemical characteristics of patients with and without heart failure
TAble 2 Comparison of echocardiographic characteristics of patients with and without heart failure Heart failure
Heart failure
Without (n=68)
With (n=92)
P
Aortic diameter, mm
32.66±3.73
32.80±4.05
0.83
0.14
Left atrium diameter, mm
38.37±4.71
40.67±5.81
0.01
0.03
Right atrium diameter, mm
36.40±3.67
37.84±5.27
0.06
39.56±4.59
39.68±6.55
0.90
Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus Marcelo Utrera-Lagunas MD1, Arturo Orea-Tejeda MD1, Lilia Castillo-Martínez PhD1, Karla Balderas-Muñoz MD1, Candace Keirns-Davis MD2, Sarahi Espinoza-Rosas BSc1, Néstor Alonso Sánchez-Ortíz BSc1, Gabriela Olvera-Mayorga BSc1 M Utrera-Lagunas, A Orea-Tejeda, L Castillo-Martínez, et al. Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus. Exp Clin Cardiol 2013;18(1):e44-e46. BACKGROUND: Diabetes is a major risk factor for heart failure (HF), although the pathophysiological processes have not been clarified. OBjECTivE: To determine the prevalence of HF and of abnormal myocardial perfusion in diabetic patients evaluated using technetium (99m) sestamibi single-photon emission computed tomography. METHODS: An observational cross-sectional study was conducted that included patients with type 2 diabetes mellitus who underwent echocardiography to diagnose HF and a pharmacological stress test with intravenous dipyridamole to examine cardiac scintigraphic perfusion abnormalities. Clinical and biochemical data were also collected. RESULTS: Of the 160 diabetic patients included, 92 (57.6%) were in HF and 68 (42.5%) were not. When patients were stratified according to the
T
he prevalence of diabetes has increased. It is believed that in 2000, there were 3.5 million individuals 65 years of age and older who were affected, and this number was projected to have increased to five million by the end of 2010 (1). These patients are more likely to develop heart failure (HF) compared with the general population, and the RR is particularly marked in younger individuals (2). Thus, diabetes has been recognized as a major risk factor for HF according to data published in epidemiological studies. The two most common risk factors for the development of HF in diabetic patients are hypertension and coronary artery disease (CAD) (3). However, the diagnosis of CAD in the studies reported in the literature is based on clinical information from medical records and electrocardiographic findings (4-6). The pathophysiological process has not been adequately explained, especially in the absence of obstructive epicardial coronary artery lesions. In such cases, an evaluation of myocardial perfusion may be a more effective method of diagnosing myocardial ischemia than coronary angiography. Single-photon emission computed tomography (SPECT) has recently emerged with the expectation that it will emulate the success of positron emission tomography-computed tomography as a hybrid imaging modality. Proponents of SPECT are confident that the addition of computed tomography will lead to a renaissance for SPECT in nuclear cardiology and in other functional studies, and revitalize traditional nuclear medicine (7). It has become accepted as the most accurate method for assessing myocardial viability in patients with CAD and impaired left ventricular function (8). The objective of the present study was to determine the prevalence of HF in patients with type 2 diabetes mellitus and its relationship with ischemic heart disease identified by abnormal perfusion on technetium (99m) sestamibi SPECT in patients who demonstrate no visible obstructive coronary lesions in angiographic evaluations.
METHODS
The present observational, cross-sectional study included patients 18 years of age or older with type 2 diabetes who attended the Internal Medicine Service at Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán” (INNCMSZ, Mexico) between February 2011 and January 2012, and agreed to participate.
presence of abnormal myocardial perfusion, those with abnormal perfusion had a higher prevalence of HF (93%) than those with normal perfusion (44.4%) (P12 mm, a posterior wall thickness >12 mm and a characteristic pattern of transmitral Doppler flow (slow, inverted, pseudonormal or restrictive) (9). To evaluate the presence of ischemic heart disease, all patients underwent a pharmacological stress test induced with intravenous dipyridamole infusion at a dose of 0.14 mg/kg weight over 4 min. A saline solution of sestamibi Tc99m (25 μCi [927 MBq]) was administered intravenously during the rest period. In the rest-stress protocol, the patients consumed a fat-rich meal to accelerate hepatobiliary excretion before data acquisition. The images were taken 40 min after sestamibi administration and were compared with the images obtained at rest. The images at rest and during stress were obtained using a Siemens Multispect 2HD/HD gamma camera (Siemens, USA) with two rectangular detectors with 59 photomultiplier tubes each, a Gantry rotation system and a high-resolution collimator of parallel holes. Images were obtained over an anterior arc of 180° at intervals of 6° per step, and 40 s of acquisition beginning 40 min after the administration of the tracer. Evaluation and interpretation were performed according to American Society of Nuclear Cardiology recommendations by two experts in nuclear medicine and nuclear cardiology who were blinded to the clinical characteristics of the patients.
1HF
Clinic, Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubirán”, 2Massachusetts General Hospital, Boston, Massachsetts, USA. Correspondence: Dr Lilia Castillo-Martínez, HF Clinic INCMNSZ, Providencia 1218-A Int. 402, Colonia del Valle Delegación Benito Juárez 03100, México, DF México. Telephone/fax 5255-55-13-93-84, e-mail [email protected]
e44
©2013 Pulsus Group Inc. All rights reserved
Exp Clin Cardiol Vol 18 No 1 2013
Abnormal perfusion heart failure risk in diabetes
TAble 1 Comparison of clinical and biochemical characteristics of patients with and without heart failure
TAble 2 Comparison of echocardiographic characteristics of patients with and without heart failure Heart failure
Heart failure
Without (n=68)
With (n=92)
P
Aortic diameter, mm
32.66±3.73
32.80±4.05
0.83
0.14
Left atrium diameter, mm
38.37±4.71
40.67±5.81
0.01
0.03
Right atrium diameter, mm
36.40±3.67
37.84±5.27
0.06
39.56±4.59
39.68±6.55
0.90
