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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 4  |  Issue : 2  |  Page : 282-288

Postexercise stunning in type II diabetes mellitus assessed by 2D speckle tracking echocardiography and gated-SPECT myocardial perfusion imaging


Department of Cardiology, Faculty of Medicine (Girls), Al-Azhar University, Cairo, Egypt

Date of Submission28-Apr-2020
Date of Decision16-May-2020
Date of Acceptance19-May-2020
Date of Web Publication29-Jun-2020

Correspondence Address:
Assesstant Prof Taghreed A Ahmed
Faculty of Medicine (Girls), Al Azhar University, Cairo
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjamf.sjamf_46_20

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  Abstract 


Background Type II diabetes mellitus (DM) is usually associated with a number of myocardial structural and functional changes. Noninvasive imaging techniques play a key role in the identification of these changes.
Objective Detection of postexercise myocardium stunning in type II DM patients by 2 dimensional speckle tracking Echo (2D STE) and single photon emission computed tomography (SPECT) imaging.
Patients and methods The authors enrolled 60 symptomatic patients with type II DM who were classified into different groups: Group I included 17 patients with normal left ventricular global longitudinal strain (LVGLS) and negative SPECT; group II included 43 patients with impaired LVGLS and negative SPECT; and group III included 10 patients with impaired LVGLS and positive SPECT. The authors evaluate LV functions and dimensions before and early after exercise by conventional, tissue Doppler, 2D STE, and gated-SPECT perfusion imaging. Coronary angiography for group III.
Results This study shows statistically significant difference between early and late gated SPECT regarding left ventricular end diastolic volume (LVEDV) and EF% between the three different groups. There were significant decrease in average LVGLS from (−20.79±1.04 pre-exercise) vs (−16.15±1.28 postexercise) in group I from (−15.98±1.75 pre-exercise) vs (−14±2.47 postexercise) in group II and from (−15.82±3.44 pre-exercise) vs (−13.48±2.75 postexercise) in group III. Eight out of 10 patientﹶs had coronary artery disease in group III.
Conclusion Transient ischemic stunning and dilatation remained a robust marker for high-risk scan especially in type II DM. LVGLS correlated well with gated SPECT in the detection of postexercise LV stunning. LVGLS is a very sensitive parameter and paramount for early detection of LV subclinical systolic dysfunction in diabetic patients.

Keywords: gated-SPECT, postexercise stunning, STE, type II diabetes mellitus


How to cite this article:
Ahmed TA, Ali MN, Attia FM. Postexercise stunning in type II diabetes mellitus assessed by 2D speckle tracking echocardiography and gated-SPECT myocardial perfusion imaging. Sci J Al-Azhar Med Fac Girls 2020;4:282-8

How to cite this URL:
Ahmed TA, Ali MN, Attia FM. Postexercise stunning in type II diabetes mellitus assessed by 2D speckle tracking echocardiography and gated-SPECT myocardial perfusion imaging. Sci J Al-Azhar Med Fac Girls [serial online] 2020 [cited 2020 Jul 11];4:282-8. Available from: http://www.sjamf.eg.net/text.asp?2020/4/2/282/288283




  Introduction Top


Diabetes mellitus (DM) can contribute to the development of structural heart disease and heart failure (HF) via systemic, myocardial, and cellular mechanisms. DM commonly causes structural heart disease and HF via myocardial ischemia/infarction; hyperglycemia and hyperinsulinemia accelerate atherosclerosis via vascular smooth muscle cell proliferation and inflammation [1].

Early detection of diabetic heart disease is of paramount importance because timely lifestyle modifications and medical interventions could prevent or delay the subsequent development of HF, which is considered one of the major burdens for health insurance costs [2].

Objective

The aim of this study was detection of postexercise myocardium stunning in type II DM patients by 2 dimensional speckle tracking Echo (2D STE) and single photon emission computed tomography (SPECT) myocardial perfusion imaging.


  Patients and methods Top


A written informed consent was taken from all participants after proper explanation of the study.

Study cohort

This study was conducted on 60 patients with type II DM who were presented with chest pain or dyspnea and who were referred to myocardial perfusion imaging to investigate the presence or absence of coronary artery disease (CAD). Enrollment of eligible patients was started in November 2018 till October 2019 from the Cardiology Outpatient Clinic, Al Zahraa University Hospital.

We exclude patients with documented ischemic heart disease, significant valve disease, hypertension (HTN), left bundle branch block (LBBB), or pacemaker, and patients with arrhythmias (AF, frequent premature ventricular contraction (PVCs), or APCs). Written consents have been signed according to the Institutional Ethics Committee Recommendations.

Methods

Detailed history, medical therapy, 12-lead ECG, and stress exercise ECG were done in all cases; also weight, height, and BMI were recorded.

Laboratory investigations

We asked for fasting blood sugar, postprandial blood sugar, HbA1c, total serum cholesterol level, serum triglycerides level, and low-density lipoprotein and high-density lipoprotein for all the patients.

Transthoracic echocardiography

Transthoracic echocardiography was performed using the GE Vivid-E9 (General Electric Company, Florida, USA) system with tissue Doppler imaging (TDI) capability. We use multifrequency (2.5–3.5 MHz) matrix probe M3S with simultaneous ECG physio signal displayed with all recorded echo images and loops. For image acquisition, three cardiac cycles were taken in each view with the patient holding his or her breath. All images were digitally stored for off-line analysis [EchoPAC (premature atrial contraction).GE VERSION 113–202]. All parameters were taken according to the ASE standards and recommendations of the European Association of Cardiovascular Imaging.

All the following parameters were obtained at rest and at 5–10 min postexercise.

Assessment of the LV

LV assessment was done using 2D-guided M-mode echocardiography to assess LVEDD, LVESD, IVSD, LVPWD, and FS. 2D echocardiography was used to assess EF% (Simpson method, segmental wall motion abnormalities). PWD was performed to assess transmitral maximal velocities (peak (E), peak (A) velocities, the E/A ratio, and deceleration time of early mitral flow) and using TDI to evaluate peak Ś, É, and Á velocities.

Two-dimensional speckle tracking: Speckle tracking analysis performed on LV was obtained in apical 4, 2, and 3 chambers. Global strain was assessed by averaging the strain of all segments.

Myocardial perfusion imaging was done to assess LV systolic function, systolic and diastolic volumes, and to detect ischemia by 99mTc-sestamibi.

Coronary angiography was done for all patients with positive SPECT.

Statistical analysis

Independent t test: for testing statistically significant difference between the means of the two groups in each classification, analysis of variance test for testing statistically significant difference between the means of more than two groups, Pearson’s correlation test with the determination of the correlation coefficient (r) to test a positive or negative relationship between two variables.


  Results Top


Patients characteristics

The current study was conducted on 60 symptomatic diabetic patients, who were classified into three groups (I, II, and III) according to average left ventricular global longitudinal strain (LVGLS) and gated SPECT. Group I: patients with normal LVGLS and negative SPECT (no perfusion defect); group II: patients with impaired LVGLS and negative SPECT (no perfusion defect); and Group III: patients with impaired LVGLS and positive SPECT (presence of perfusion defect). There were 17 patients in group I, 43 patients in group II, and 10 patients in group III. Mean age (51±9.10) in group I, (51.30±9.63) in group II, and (52.9±6.74) in group III. There were two men and 15 women in group I, nine men and 24 women in group II, and four men and six women in group III.

Correlation between LVGLS and different factors (HbA1c, duration of diabetes, medication): There was significant strong negative correlation between control of diabetes (HbA1C) and pre-exercise and postexercise LV 2D GLS, as shown in [Table 1].
Table 1 Linear regression between HbA1c and average LVGLS

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We found significant positive correlations between the duration of DM and impairment of LVGLS (P0.015) and also we found that patients with IDDM had more impairment of LVGLS than patients on NIDDM (P=0.007).

Echocardiographic data

Conventional echocardiography

In group I there was statistically significant impairment of LV 2D GLS postexercise (−20.79±1.04 pre-exercise) vs (−16.15±1.28 pos exercise); P value 0.001, average Ś (6.18±1.06 vs 5.67±0.91postexercise as shown in [Figure 1] and [Table 2].
Figure 1 Decrease of LVGLS from (−20) pre-exercise to (−16%) postexercise.

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Table 2 Comparison between pre-exercise and postexercise as regards the different echo modalities in group I

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There were statistically significant differences between pre exercise and post exercise in the following parameters average Ś (P value 0.006), E/É (9.80±3.85 vs 11.90±4.61 in group II postexercise) P value 0.001, LV 2D GLS (−15.98±1.75 pre-exercise) vs (−14±2.47 postexercise), P value 0.0001 as shown in [Figure 2] and [Table 3].
Figure 2 Significant decrease of LVGLS from (−14.7) pre-exercise to (−11.9%) postexercise.

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Table 3 Comparison between pre-exercise and postexercise as regards the different echo modalities in group II

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In group III, there was statistically significant difference between pre-exercise and postexercise in :left ventricular end systolic volume (LVESV), 2D LVEF, MV E/é ratio (12.18±5.86 vs 14.85±4.03 postexercise) P value 0.008, average Ś(4.98±0.93 vs 4.44±0.78 postexercise in group III) P value 0.003, LVGLS (−15.82±3.44 pre-exercise) vs (−13.48±2.75 postexercise) with P value 0.001 as shown in [Figure 3] and [Table 4].
Figure 3 Decrease of LVGLS from (−14.8) pre-exercise to (−10.9%) postexercise.

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Table 4 Comparison between pre and postexercise as regards the different echo modalities in group III

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Comparison between early and late gated SPECT LVEF and volumes in different groups.

There is statistically significant difference between early and late gated SPECT in left ventricular end diastolic volume (LVEDV) and LVEF, but nonsignificant difference in LVESV in group I; in group II there was statistically significant difference between early and late gated SPECT in LVEDV and LVEF but nonsignificant difference in LVESV. But in group III there is statistically significant difference between early and late gated SPECT in LVEDV and LVEF and nonsignificant difference in LVESV as shown in [Table 5].
Table 5 Comparison between early and late gated SPECT LVEF and volumes in different groups

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Coronary angiography that was done for patients in group III showed seven patients with multivessel disease for CABG, one patient with single vessel disease, and two patients with normal coronary arteries.


  Discussion Top


Our study demonstrates that there was significant strong negative correlation between HbA1C and resting LVGLS and significant moderate negative correlation with postexercise LV 2D GLS and any increase in HbA1c by 1 will decrease Pre LV 2D GLS by 1.31%, and any increase in HbA1c by 1; there was additional decrease postexercise of LV 2D GLS by 0.746% and this is due to the formation of advanced glycation end products that leads to increased fibrosis [1]. This result was concordant to the result of Melissa Leung et al. [3] who concluded that elevated HbA1C is associated with impairment of GLS and improvements in glycemic control through the decrease of HbA1C over a 12-month period which led to improvements in LV systolic using 2D GLS. But our result was discordant with the result of von Bibra et al. [4] which may be due to the small number of patients in his research (25 patient) or because he used a less sensitive parameter which is (Ś) for the detection of LV systolic function.

In our study, we found that exercise can unmask LV systolic dysfunction as in group I that became impaired postexercise and this results were concordant with the result of Clothilde Philouze et al. [5], who found exercise (by using dobutamine stress echo) can unmask early left ventricular dysfunction in asymptomatic patients with uncomplicated type 2 diabetes.

In the patients in group I, 2D LVEF% shows no significant statistical differences after exercise and this may be due to the short duration of DM for this group of patients or because in this group there were only three patients on insulin treatment and the others were on oral therapy. And these results were concordant with the result of Ju‑Hua et al. [6], which conclude that GLS is the first parameter that gets affected in diabetic cardiomyopathy.

In group III, we found statistically significant difference between pre-exercise and postexercise 2D LVEF% (that already impaired in this group of patients and became more impaired postexercise) and this owing to the effect of ischemic myocardium on LV systolic function. These results were concordant with the result of Niklas et al. [7], who conclude that diabetes reduces systolic left ventricular function (LVEF%) in patients with or without CAD.

There was more impairment of GLS postexercise in both groups (groups II and III) and these results were concordant with the result of Ify and Mordi et al. [8] which showed more impairment of GLS in diabetic patients after stress ECG. But we found also more impairment of GLS in patients with positive G-SPECT (group III) than those with negative G-SPECT (group II) and these results were concordant with the results of Wierzbowska-Drabik et al. [9] which found more impairment of GLS in diabetic patients with CAD than others without CAD.

In group I, diastolic function parameters in the form of E/A ratio or E/é ratio in patients show no significant statistical differences after exercise and this may be due to this group of patients having more controllable DM and low HbA1C than others.

But in groups II and III we found statistically significant differences in the more sensitive parameter E/é ratio between the pre-exercise and postexercise state and both parameters (E/A ratio and E/é ratio) show statistically significant differences between the pre-exercise and postexercise state in patients with impaired GLS and positive gated SPECT and these results were concordant with the result of Kamil Ashour [10].

Our SPECT study concludes that LVEDV and LVEF% in (group I) shows statistically significant difference (but the value of differences is <5%) between early and late gated SPECT. Also, patients in group II shows statistically significant difference between early and late gated SPECT in LVEDV and LVEF and the value of differences were about 6%. And these differences in spite of negative gated SPECT may be due to the effect of DM on the coronary microvasculature and endothelial proliferation and subsequent fibrosis. These results were concordant with the result of Adele Ferro et al. [11] which showed a drop of LVEF postexercise gated SPECT even in the absence of epicardial coronary artery stenosis.

In group III, we found a statistically significant drop of LVEF in the early gated SPECT in comparison to the rest gated SPECT and this drop was about 11%. These differences in LVEF were associated with statistically significant increase of LVEDV postexercise, which is due to the presence of epicardial coronary artery stenosis which is detected by the presence of defect in MPI and coronary angiography, This result was concordant with Fernando Mute et al. [12], who shows a significant drop in LVEF at early gated SPECT in patients with epicardial coronary artery stenosis and the value of drop was related to the extent of CAD.In our study, patients with multivessel coronary artery disease show lowest GLS more than other patients, and these results were concordant with the result of Vrettos et al. [13] which shows significant reverse correlations between extension of CAD and global longitudinal strain. Also they showed a more stunning a decrease in LVEF% and increased LV end-diastolic volume (transient ischemic dilatation). These results were concordant with the result of Tali Sharir, which show significant correlations between post-stress transient ischemic dilatation and extent of CAD [14].


  Conclusion Top


Transient ischemic dilatation remained a robust and important marker for high-risk scan, especially in type II DM. LVGLS correlated well with gated SPECT in the detection of post-exercise LV stunning. Also, LVGLS is a very sensitive parameter and paramount for early detection of LV subclinical systolic dysfunction in diabetic patients.

Recommendation

Further works are needed to confirm that diabetic symptomatic patients with normal GLS have no epicardial CAD. Extra efforts are needed for control of diabetes, as it has a deleterious effect on LV function.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Type 2 diabetes mellitus and heart failure: a scientific statement from the American Heart Association and the Heart Failure Society of America. Circulation 2019; 140:e294–e324.  Back to cited text no. 1
    
2.
Russo C, Jin Z, Elkind MSV, Rundek T, Homma S et al. Prevalence and prognostic value of subclinical left ventricular systolic dysfunction by global longitudinal strain in a community-based cohort. Eur J Heart Fail 2014; 16:1301–1309.  Back to cited text no. 2
    
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Leung M, Biostat M, Wong VW, Hudson M, Dominic Y et al. Impact of improved glycemic control on cardiac function in type 2 diabetes mellitus. Circ Cardiovasc Imaging 2016; 9:17.  Back to cited text no. 3
    
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Von Bibra H, Hansen A, Dounis V, Bystedt T, Malmberg K, Rydén L. Augmented metabolic control improves myocardial diastolic function and perfusion in patients with non-insulin dependent diabetes. Heart 2004; 90:1483–1484.  Back to cited text no. 4
    
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Philouze C, Nottin S, Benamor A, Barthez O, Aboukhoudir F. Dobutamine stress echocardiography unmasks early left ventricular dysfunction in asymptomatic patients with uncomplicated type 2 diabetes. JASE 2018; 625–1147.  Back to cited text no. 5
    
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Liu J‑H, Chen Y, Yuen M, Zhen Z, Wing‑Sze Chan C, Siu‑Ling Lam K et al. Incremental prognostic value of global longitudinal strain in patients with type 2 diabetes mellitus. Cardiovasc Diabetol 2016; 15:22.  Back to cited text no. 6
    
7.
Niklas FE, Michael K, Miriam B, Jan M-B., Michael JZ. Eur J Endocrinol 2011; 165 945–951.  Back to cited text no. 7
    
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Ify R, Mordi J. Cardiovasc Dev Dis 2019; 6:18.  Back to cited text no. 8
    
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Wierzbowska-Drabik K, Trzos E, Kurpesa M, Rechcinski T, Miskowiec D, Cieslik-Guerra U et al. Effect of DM on LV contractility in patients with ischemic heart disease. Eur Heart J Cardiovasc Imaging 2017; 0:1–11.  Back to cited text no. 9
    
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Kamil Ashour. Early detection of diastolic dysfunction in diabetic patients. J Heart Cardiovasc Res 2018; 2:114.  Back to cited text no. 10
    
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Ferro A, Petretta M, Acampa W, Fiumara G, Daniele S, Petretta MP et al. Post-stress left ventricular ejection fraction drop in patients with diabetes: a gated myocardial perfusion imaging study. BMC Cardiovasc Disord 2013; 13:99.  Back to cited text no. 11
    
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Mute F, Giubbini R, Vitola J, Lusa L, Sobic-Saranovic D, Peix A et al. J Nucl Cardiol 2014; 21:1168–1176.  Back to cited text no. 12
    
13.
Vrettos A, Dawson D, Grigoratos C. Correlation between global longitudinal peak systolic strain and coronary artery disease severity as assessed by the angiographically derived SYNTAX score. Echo research and practice 2016; 16-0005.  Back to cited text no. 13
    
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Sharir T. Transient ischemic dilation: an old but notobsolete marker of extensive coronary artery disease. J Nucl Cardiol Received Sep 4, 2017. 125–164.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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