Arq Bras Cardiol abc Arquivos Brasileiros de Cardiologia Arq. Bras. Cardiol. 0066-782X 1678-4170 Sociedade Brasileira de Cardiologia - SBC PYFMwhRKftWyCVjcZqFmzSH S0066-782X2019000800216 10.5935/abc.20190164 Short Editorial New Method Improves the Evaluation of Subclinical Left Ventricular Dysfunction in Type 2 Diabetes Mellitus 0000-0001-7768-2562 Askin Lutfu Tanrıverdi Okan Tibilli Hakan Turkmen Serdar Arastirma Hastanesi Adiyaman Universitesi Egitim Adıyaman Centry Turkey Adiyaman Universitesi Egitim ve Arastirma Hastanesi - Cardiology, Adıyaman, Centry - Turkey Mailing Address: Lutfu Askin, Adiyaman Universitesi Egitim ve Arastirma Hastanesi - Cardiology - Kardiyoloji Bölümü Adıyaman Centry 2230 - Turkey. E-mail: lutfuaskin23@gmail.com 02 09 2019 08 2019 113 2 216 217 This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Keywords Antioxidants/pharmacology Apoptosis/drug effects Diabetes Mellitus Reactive Oxygen Species Myocardial Systole Dyastole Heart Failure

Tei et al.1 firstly described the myocardial performance index (MPI), which is showing both systolic and diastolic functions of the left ventricle. As a prognostic marker increased MPI has been shown to be an independent predictor of mortality and morbidity in various diseases such as myocardial infarction, hypertension, diabetes, and heart failure.2,3 Askin et al.4 showed that left ventricular (LV) diastolic and systolic functions were negatively affected in prediabetic patients. In addition, MPI can also be used in the assessment of abnormal cardiac function parameters in prediabetic patients. Furthermore, the most prominent feature of our method is that it can be obtained in a short period of time with easily available equipment. It is important to identify subclinical left ventricular diastolic dysfunction (LVDD) for clinical prevention before significant LVDD occurs. For this purpose, MPI is used to identify subclinical LVD in type 2 diabetes mellitus (DM).

Presystolic wave (PSW) measurement is obtained via doppler examination of LV outflow tract (LVOT).5,6 Kul et al.7 found that the PSW is associated with subclinical LVDD in patients with type 2 diabetes. PSW is an easily measurable echocardiographic parameter obtained in late diastole and can predict subclinical left ventricular dysfunction in patients with type 2 diabetes. Possible causes of PSW formation are impaired LV compliance and increased LV stiffness, which are also leading causes of PSW in diabetic patients among others. Furthermore, the relationship between PSW and LVDD has been proven.5

Stahrenberg et al.8 reported that LV diastolic dysfunction is associated with glucose metabolism in a broad spectrum from impaired glucose tolerance to overt diabetes. Simone et al.9 have recently reported that the risk of heart failure was increased markedly with type 2 diabetes, which was independent of myocardial infarction and hypertension (HT). Therefore; in the medical literature, the term ''diabetic cardiomyopathy'' has been proposed to be used in cases of ventricular dysfunction in the absence of coronary artery disease and HT.10

Hyperglycemia may result in the build-up of myocardial proteins via excessive accumulation of increased glycosylated products (AGE) and this may cause rigid myocardium. Accumulation of AGEs results in reduced myocardial relaxation by disrupting cross-links between collagen molecules. Hyperglycemia may also cause myocyte apoptosis, accelerated myocardial cell loss, decreased ventricular contraction, and systolic dysfunction. In conclusion, these phenomena cause decreased LV systolic and diastolic functions in diabetic patients.11,12

Short Editorial related to the article: Presystolic Wave is Associated with Subclinical Left Ventricular Dysfunction Assessed by Myocardial Performance Index in Type 2 Diabetes Mellitus

 References 1 Tei C, Nishimura RA, Seward JB, Tajik AJ. Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements. J Am Soc Echocardiogr, 1997; 10(2):169-78. Tei C Nishimura RA Seward JB Tajik AJ Noninvasive Doppler-derived myocardial performance index: correlation with simultaneous measurements of cardiac catheterization measurements J Am Soc Echocardiogr, 1997 10 2 169 178 2 Mishra RK, Kizer JR, Palmieri V, Roman MJ, Galloway JM, Fabsitz RR, et al. Utility of the myocardial performance index in a population with high prevalences of obesity, diabetes, and hypertension: the strong heart study. Echocardiography. 2007;24(4):340-7. Mishra RK Kizer JR Palmieri V Roman MJ Galloway JM Fabsitz RR Utility of the myocardial performance index in a population with high prevalences of obesity, diabetes, and hypertension: the strong heart study Echocardiography 2007 24 4 340 347 3 Carluccio E, Biagioli P, Alunni G, Murrone A, Zuchi C, Biscottini E, et al. Improvement of myocardial performance (Tei) index closely reflects intrinsic improvement of cardiac function: assessment in revascularized hibernating myocardium. Echocardiography. 2012;29(3):298-306. Carluccio E Biagioli P Alunni G Murrone A Zuchi C Biscottini E Improvement of myocardial performance (Tei) index closely reflects intrinsic improvement of cardiac function: assessment in revascularized hibernating myocardium Echocardiography 2012 29 3 298 306 4 Askin L, Cetin M, Tasolar H, Akturk E. Left ventricular myocardial performance index in prediabetic patients without coronary artery disease. Echocardiography. 2018;35(4):445-9. Askin L Cetin M Tasolar H Akturk E Left ventricular myocardial performance index in prediabetic patients without coronary artery disease Echocardiography 2018 35 4 445 449 5 Mittal SR, Pancholi N. Left ventricular outflow tract presystolic flow velocity - another marker of left ventricular diastolic function. Int J Cardiovasc Imaging. 2002;18(4)249-56. Mittal SR Pancholi N Left ventricular outflow tract presystolic flow velocity - another marker of left ventricular diastolic function Int J Cardiovasc Imaging 2002 18 4 249 256 6 Korkmaz L, Akyüz AR, Gurbak I, Erkan H, Dursun I, Celik S, et al. Presystolic A wave may predict increased arterial stiffness in asymptomatic individuals. Blood Press Monit. 2016;21(3):144-8. Korkmaz L Akyüz AR Gurbak I Erkan H Dursun I Celik S Presystolic A wave may predict increased arterial stiffness in asymptomatic individuals Blood Press Monit 2016 21 3 144 148 7 Kul S, Dursun I, Ayhan S, Sayin MR, Uçuncu O, Bulbul NE, et al. Presystolic Wave is Associated with Subclinical Left Ventricular Dysfunction Assessed by Myocardial Performance Index in Type 2 Diabetes Mellitus. Arq Bras Cardiol. 2019; 113(2):207-215 Kul S Dursun I Ayhan S Sayin MR Uçuncu O Bulbul NE Presystolic Wave is Associated with Subclinical Left Ventricular Dysfunction Assessed by Myocardial Performance Index in Type 2 Diabetes Mellitus Arq Bras Cardiol 2019 113 2 207 215 8 Stahrenberg R, Edelmann F, Mende M, Kockskämper A, Düngen HD, Scherer M, et al. Association of glucose metabolism with diastolic function along the diabetic continuum. Diabetologia. 2010;53(7):1331-40. Stahrenberg R Edelmann F Mende M Kockskämper A Düngen HD Scherer M Association of glucose metabolism with diastolic function along the diabetic continuum Diabetologia 2010 53 7 1331 1340 9 de Simone G, Devereux RB, Chinali M, Lee ET, Galloway JM, Barac A, et al. Diabetes and incident heart failure in hypertensive and normotensive participants of the Strong Heart Study. J Hypertens. 2010;28(7):353-60. de Simone G Devereux RB Chinali M Lee ET Galloway JM Barac A Diabetes and incident heart failure in hypertensive and normotensive participants of the Strong Heart Study J Hypertens 2010 28 7 353 360 10 Litwin SE. Diabetes and the heart: is there objective evidence of a human diabetic cardiomyopathy? Diabetes. 2013;62(10):3329-30. Litwin SE Diabetes and the heart: is there objective evidence of a human diabetic cardiomyopathy? Diabetes 2013 62 10 3329 3330 11 Singh R, Barden A, Mori T, Beilin L. Advanced glycation endproducts: a review. Diabetologia. 2001;44(2):129-46 Singh R Barden A Mori T Beilin L Advanced glycation endproducts: a review Diabetologia 2001 44 2 129 146 12 Bojunga J, Nowak D, Mitrou PS, Hoelzer D, Zeuzem S, Chow KU. Antioxidative treatment prevents activation of death-receptor and mitochondrion-dependent apoptosis in the hearts of diabetic rats. Diabetologia 2004;47(12):2072-80. Bojunga J Nowak D Mitrou PS Hoelzer D Zeuzem S Chow KU Antioxidative treatment prevents activation of death-receptor and mitochondrion-dependent apoptosis in the hearts of diabetic rats Diabetologia 2004 47 12 2072 2080 Minieditorial Novo Método Melhora Avaliação da Disfunção Ventricular Esquerda Subclínica no Diabetes Mellitus Tipo 2 0000-0001-7768-2562 Askin Lutfu Tanrıverdi Okan Tibilli Hakan Turkmen Serdar Adiyaman Universitesi Egitim ve Arastirma Hastanesi - Cardiology, Adıyaman, Centry - Turquia Correspondência: Lutfu Askin, Adiyaman Universitesi Egitim ve Arastirma Hastanesi - Cardiology - Kardiyoloji Bölümü Adıyaman Centry 2230 - Turquia. E-mail: lutfuaskin23@gmail.com Palavras-chave Antioxidantes/farmacologia Apoptose/efeitos dos fármacos Diabetes Mellitus Espécies Reativas de Oxigênio Miocárdio Sístole Diástole Insuficiência Cardíaca

Tei et al.1 foram os primeiros a descrever o índice de desempenho miocárdico (IPM), que mostra as funções sistólica e diastólica do ventrículo esquerdo (VE). Enquanto marcador prognóstico, o IPM tem se mostrado um preditor independente de mortalidade e morbidade em várias doenças, como infarto do miocárdio, hipertensão, diabetes e insuficiência cardíaca.2,3 skin et al.4 descreveram que as funções diastólica e sistólica do VE foram afetadas negativamente em pacientes pré-diabéticos. Além disso, o índice também pode ser usado para avaliar parâmetros anormais de função cardíaca em pacientes pré-diabéticos. A característica mais proeminente do nosso método é que ele pode ser obtido dentro de um curto período com equipamentos facilmente disponíveis. É importante identificar a disfunção diastólica ventricular esquerda subclínica (DDVE) para a prevenção clínica antes que seja significativa. Assim, o IPM é usado para identificar DVE subclínica no diabetes mellitus tipo 2 (DM2).

A medida da onda pressistólica (OPS) é obtida por meio de exame doppler da via de saída do VE (VSVE).5,6 Kul et al.7 descobriram que a OPS está associada à DVE subclínica em pacientes com DM2. Ou seja, as OPS são um parâmetro ecocardiográfico facilmente mensurável, obtido na diástole tardia, que pode predizer DVE subclínica em pacientes com DM2. Possíveis causas da formação das OPS são a complacência prejudicada e aumento da rigidez do VE, que também são as principais causas de OPS em pacientes diabéticos, entre outros. Logo, a relação entre OPS e DDVE foi comprovada.5

Stahrenberg et al.8 reportaram associaão da DDVE com o metabolismo da glicose em um amplo espectro, da tolerância diminuída à glicose ao diabetes evidente. Simone et al.9 relataram recentemente um risco de insuficiência cardíaca acentuadamente maior com diabetes tipo 2, independentemente da ocorrência de infarto do miocárdio e hipertensão. Assim sendo, na literatura médica, o termo “cardiomiopatia diabética” tem sido proposto em casos de disfunção ventricular na ausência de doença arterial coronariana e hipertensão.10

A hiperglicemia pode resultar no acúmulo de proteínas miocárdicas por meio do acúmulo excessivo de produtos da glicação avançada (AGE), e isso pode causar rigidez do miocárdio. O acúmulo de AGEs causa redução do relaxamento miocárdico ao interromper as ligações cruzadas entre as moléculas de colágeno. A hiperglicemia também pode causar apoptose de miócitos, perda acelerada de células miocárdicas, diminuição da contração ventricular e disfunção sistólica. Em conclusão, esses fenômenos causam diminuição das funções sistólica e diastólica do VE em pacientes diabéticos.11,12

Minieditorial referente ao artigo: Onda Pressistólica Associada à Disfunção Ventricular Esquerda Subclínica e Avaliada com Base no Índice de Performance Miocárdica em Pacientes com Diabetes Mellitus Tipo 2