Diabetes Metab J.  2023 Jul;47(4):470-483. 10.4093/dmj.2023.0036.

The Role of Echocardiography in Evaluating Cardiovascular Diseases in Patients with Diabetes Mellitus

• Lee SH
• Park JH

• KMID: 2544726
• DOI: http://doi.org/10.4093/dmj.2023.0036

Abstract

Patients with diabetes mellitus are highly susceptible to cardiovascular complications, which are directly correlated with cardiovascular morbidity and mortality. In addition to coronary artery disease, there is growing awareness of the risk and prevalence of heart failure (HF) in patients with diabetes. Echocardiography is an essential diagnostic modality commonly performed in patients with symptoms suggestive of cardiovascular diseases (CVD), such as dyspnea or chest pain, to establish or rule out the cause of symptoms. Conventional echocardiographic parameters, such as left ventricular ejection fraction, are helpful not only for diagnosing CVD but also for determining severity, treatment strategy, prognosis, and response to treatment. Echocardiographic myocardial strain, a novel echocardiographic technique, enables the detection of early changes in ventricular dysfunction before HF symptoms develop. This article aims to review the role of echocardiography in evaluating CVD in patients with diabetes mellitus and how to use it in patients with suspected cardiac diseases.

Keyword

Coronary artery disease; Diabetes mellitus; Diagnosis; Echocardiography; Heart failure

Figure

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  Fig. 1. There are two phenotypes of diabetic cardiomyopathy: the restrictive phenotype, characterized by concentric left ventricular (LV) hypertrophy and diastolic dysfunction; and the dilated phenotype, characterized by LV dilatation and both systolic and advanced diastolic dysfunction. It is important to note that some patients exhibiting a restrictive phenotype may transition to a dilated phenotype. RA, right atrium; Ao, aorta; LA, left atrium; RV, right ventricle; LVEDVi, indexed left ventricular end-diastolic volume; LVEF, left ventricular ejection fraction; HFpEF, heart failure with preserved ejection fraction; SGLT2i, sodium glucose cotransporter 2 inhibitor; HFrEF, heart failure with reduced ejection fraction; HFmrEF, heart failure with mildly reduced ejection fraction. aAngiotensin receptor-neprilysin inhibitor/angiotensin converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and ivabradine.

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  Fig. 2. The use of conventional echocardiography for the assessment of cardiac function and structure. (A) Assessment of left ventricular (LV) geometry using two-dimensional (2D) and M-mode echocardiography, (B) assessment of LV systolic function using 2D echocardiography, (C) assessment of LV diastolic function using Doppler echocardiography and tissue Doppler imaging, (D) assessment of valvular function using 2D echocardiography and color Doppler imaging, (E) assessment of RV size and systolic function using 2D and M-mode echocardiography, and (F) assessment of pulmonary artery pressure using 2D and Doppler echocardiography. Ao, aorta; LA, left atrium; LVEF, left ventricular ejection fraction; TDI, tissue Doppler imaging; AV, aortic valve; MV, mitral valve; VHD, valvular heart disease; RV, right ventricle; RVFAC, right ventricular fractional area change; TAPSE, tricuspid annular plane systolic excursion; IVC, inferior vena cava; RA, right atrium; TR Vmax, maximal velocity of tricuspid regurgitation.

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  Fig. 3. The demonstration of Bull’s eye maps using strain echocardiography. (A) A normal subject without cardiovascular risk factors and normal coronary angiography shows a normal Bull’s eye pattern with preserved left ventricular global longitudinal strain (LVGLS) value (–26.5%). (B) A patient with diabetes complaining of dyspnea can show a globally decreased LVGLS (–15.6%) in the Bull’s eye map. There was no significant obstructive coronary artery disease (CAD), as seen in the panel below. (C) In a patient with diabetes and obstructive CAD at the left anterior descending coronary artery (arrowheads), decreased regional strain values can be observed in the Bull’s eye map (arrows). A2C, apical 2-chamber; A3C, apical 3-chamber; A4C, apical 4-chamber; GLS, global longitudinal strain; RCA, right coronary artery; LCA, left coronary artery.

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  Fig. 4. A diagnostic algorithm for the evaluation of dyspnea. ECG, electrocardiography; CVD, cardiovascular disease; COPD, chronic obstructive pulmonary disease; LVH, left ventricular hypertrophy; LAE, left atrial enlargement; LBBB, left bundle branch block; BNP, B type natriuretic peptide; NT proBNP, N-terminal pro-brain natriuretic peptide; CECT, contrast enhanced computed tomography; CMR, cardiac magnetic resonance imaging.

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  Fig. 5. A diagnostic algorithm for the evaluation of chest pain. ECG, electrocardiography; CVD, cardiovascular disease; LVH, left ventricular hypertrophy; LAE, left atrial enlargement; LBBB, left bundle branch block; CECT, contrast enhanced computed tomography; CMR, cardiac magnetic resonance imaging.

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  Fig. 6. The role of echocardiography in evaluating cardiovascular diseases in patients with diabetes mellitus. PEx, physical examination; CXR, chest X-ray; ECG, electrocardiography; CBC, complete blood count; CVD, cardiovascular disease; BNP, brain natriuretic peptide; NT proBNP, N-terminal pro-brain natriuretic peptide; CAD, coronary artery disease; DiaCM, diabetic cardiomyopathy; HFpEF, heart failure with preserved ejection fraction.

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