Abstract
Background
Cardiovascular disease is the most common comorbidity in type 1 diabetes (T1D). Current guidelines, however, do not include routine echocardiography or cardiac biomarkers in T1D.
Objectives
To investigate if echocardiography and NT-proBNP provide incremental prognostic information in individuals with T1D without heart disease and with preserved left ventricular ejection fraction (LVEF).
Methods
A prospective cohort of individuals with T1D without heart disease and with preserved LVEF (≥45%) from the outpatient clinic were included. Follow-up was performed through Danish national registers. The association between E/e', a marker of diastolic function, from echocardiography and NT-proBNP with major adverse cardiovascular events (MACE) was tested. MACE was defined as death from all-causes, acute coronary syndromes, cardiac revascularization, incident heart failure, or stroke. Additionally, the incremental prognostic value when adding E/e' and NT-proBNP to the clinical Steno T1D Risk Engine score (including age, sex, duration of diabetes, systolic blood pressure, LDL, HbA1c, presence of albuminuria (micro-or macroalbuminuria), eGFR, smoking status, and physical activity [low, medium, high]), was examined. Follow-up was 100% complete.
Results
Of 964 individuals (mean (SD)) age 49.7 (14.5) years, 51% men, HbA1c 66 (14) mmol/mol, BMI 25.6 (4.0) kg/m2, and diabetes duration 26.1 (14.5) years), 121 (12.6%) experienced MACE during 7.5 years of follow-up. In the full multivariable model, E/e' significantly and independently predicted MACE: (HR (95%)) E/'e <8 (n=639) vs. 8–12 (n=248): 2.00 (1.23; 3.25), p=0.005, E/'e <8 vs E/e'≥12 (n=77): 3.36 (1.8; 6.1), p<0.001. Also, NT-proBNP significantly predicted outcome: NT-proBNP <150 pg/ml (n=435) vs. 150–450 pg/ml (n=386): 1.52 (0.9; 2.5), p=0.11, NT-proBNP <150 pg/ml vs NT-proBNP >450 pg/ml (n=143): 2.78 (1.6; 4.9), p<0.001. Adding both (log)E/e' and (log)NT-proBNP to the Steno T1D Risk Engine score significantly and incrementally improved risk prediction: Harrell's C-index: Steno T1D Risk Engine (AUC 0.783 (0.747; 0.818)) vs. Steno T1D Risk Engine + (log)E/e' (AUC 0.805 (0.773; 0.837)): p<0.001 and Steno T1D Risk Engine + (log)E/e' + (log) NT-proBNP (AUC 0.816 (0.783; 0.848)): p=0.002. The risk of MACE by groups of E/e' and NT-proBNP is shown in the figure.
Figure 1
Conclusion
In individuals with T1D without heart disease and with preserved LVEF, E/e' and NT-proBNP significantly improved risk prediction of cardiovascular events beyond clinical risk factors alone. Echocardiography and NT-proBNP could have a role in clinical care.
Cardiac repolarization and depolarization in people with Type 1 diabetes with normal ejection fraction and without known heart disease: a case-control study
