Left ventricular systolic function deterioration during dobutamine stress echocardiography as an early manifestation of diabetic cardiomyopathy and reversal by optimized therapeutic approach

Abstract

Diabetes mellitus has been associated with changes in the structure and function of the myocardium manifesting in the early stages of the disease as subtle systolic and diastolic dysfunction; the role of dobutamine stress echocardiography (DSE) in this setting remains unclear. We sought to evaluate the prevalence of dobutamine-induced systolic dysfunction amongst diabetic patients with normal at rest left ventricular ejection fraction and no coronary artery disease and to investigate whether an optimized therapeutic approach can reverse these abnormalities. 1,363 patients with DM referred to our echocardiography laboratory for DSE between January 2008 and June 2010 were prospectively investigated. Patients with normal left ventricular ejection fraction (LVEF) at rest and significant deterioration during peak dobutamine infusion (defined as a ≥10% decrease) in the absence of coronary artery disease or vasospasm were enrolled. They received on top of their usual treatment 5 mg perindopril and had their glycemic control intensified. At 60 days, all of them were controlled for clinical status and underwent a control DSE. 18 patients were included, there were 9 males and 9 females, mean age was 66.1 ± 10.2 years. All the patients had type II DM with a mean duration of 12.7 ± 6.6 years. They all had normal at rest echocardiographic findings with no wall motion abnormalities; mean LVEF was 62 ± 6%. At peak dobutamine, LVEF significantly deteriorated in all the patients with a mean 15 ± 5% decrease compared to baseline. After therapeutic optimization, Glycated haemoglobin improved from 8.53 ± 2.05% to 6.8 ± 0.6% (δ HbA1C = 1.73%, P = 0.001), mean LVEF at peak dobutamine infusion evolved from 47.17 ± 4.2% pre-optimization to 58 ± 4.8% at control (10.83% improvement; P < 0.001). In patients with DM and normal at rest LVEF, Dobutamine infusion during DSE can induce a significant deterioration in LVEF in the absence of coronary artery disease or vasospasm. This specific condition could be largely reversed through an optimized therapy based on a tighter metabolic control and a more stringent renin-angiotensin-aldosterone system inhibition.

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Correspondence to Sofiene Rekik.

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Movie 1: Echocardiographic loops recorded in the apical four-chamber views at rest and at low dose dobutamine infusion showing normal wall motion in all myocardial segments and normal left ventricular ejection fraction. At dobutamine-atropine peak stress, a global hypokinesia was observed with a marked deterioration in ejection fraction. (WMV 354 kb)

Movie 2: Echocardiographic loops recorded in the apical four-chamber views at rest and at low dose dobutamine infusion showing normal wall motion in all myocardial segments and normal left ventricular ejection fraction. An improved and adequate response was observed at dobutamine-atropine peak stress. (WMV 340 kb)

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Aboukhoudir, F., Rekik, S. Left ventricular systolic function deterioration during dobutamine stress echocardiography as an early manifestation of diabetic cardiomyopathy and reversal by optimized therapeutic approach. Int J Cardiovasc Imaging 28, 1329–1339 (2012). https://doi.org/10.1007/s10554-011-9938-7

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Keywords

  • Diabetes mellitus
  • Dobutamine stress echocardiography
  • Left ventricular ejection fraction