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Cardio Diabetes Medicine 2017 307

Similarly, the unique shape of the right ventricle has assess diastolic function accurately without the draw-
precluded accurate quantification using traditional backs observed with echocardiographic assessment
echocardiography. Transthoracic 3D echocardiogra- of diastolic function.
phy has the potential to overcome these limitations
resulting in precise measurements of right ventricu- SPECT (single photon emission CT)
lar size and function. Real-time 3D echocardiography Quantitative myocardial perfusion SPECT has ad-
is based on the design of an ultrasound transducer vanced significantly over the last few years provid-
with a matrix array that instantaneously acquires the ing a competitive advantage to nuclear cardiology
image contained in a pyramidal volume.Thec oncur- compared with other higher-resolution non-invasive
rentdi splay of multiple tomographic images allows imaging modalities for the detection of CAD. In par-
the anatomically correct examination of any structure ticular, gating has provided both perfusion and func-
contained withinthe volumetric image.The develop- tional information and attenuation correction SPECT
ment of new software and the use of high-perfor- has improved perfusion information. 26
mance computers now allows rapid mapping of the
volumetric image, and it is possible to simultaneously
visualize multiple superimposed planes in an interac- Treatment
tive manner. Real-time 3D echocardiographyis being The pillars in the treatment of diabetic cardiomyopa-
used in conjunction with strain rates to evaluate fur- thy are related to lifestyle changes, the regulation of
ther both regional LV systolic dysfunction and dia- blood glucose levels, modification of risk factors for
stolic dysfunction.An area where it looks especially cardiovascular disease, and the treatment of heart
promising is in predicting the response to biventric- failure.
ular pacing in patients with HF and interventricular
conduction delay. 24 Lifestyle
Smoking cessation, healthy eating habits, reduction
CT (computed tomography) in body weight and aerobic exercise are the corner-
The CAC (coronary artery calcification) score, derived stones in terms of lifestyle change. It has been shown
originally from electron-beam CT but more recent- in people with diabetes mellitus type 2 that, following
ly from multi-slice CT,has been shown to correlate reduction of their body weight and increased aerobic
strongly with the presence and severity of histolog- activity, the incidence of diabetic cardiomyopathy de-
ical and angiographic evidence of coronary athero- creased significantly. 27
sclerosis and conventional CHD risk factors, inpar-
ticular CRP, reflecting stable and unstable plaques. Glycemia and other risk factors
In 10377 asymptomatic patients, coronary calcium The setting of the level of blood glucose is an import-
has been shown to provide independent incremental ant target for the treatment of diabetic cardiomyopa-
information in addition to traditional risk factors in thy. Achieving euglycemia reduces the risk of major
the prediction of all-cause mortality. Of 101 patients cardiovascular events, such as myocardial infarction
aged17–28 years with Type I diabetes and duration or stroke, and the likelihood of developing diabet-
of diabetes over 5 years, 10.9% demonstrated CAC. ic cardiomyopathy. The modern therapeutic arsenal
Similarly CAC was significantly increased in asymp- has several effective medications to treat diabetes,
tomatic patients with Type II diabetes compared with such as metformin, sulfonylureas, glitazones, insulin,
non-diabetic subjects. 25 Although the CAC score and some modern drugs, such as GLP1 agonists and
correlates well withCAD,there are no studies to date antagonists of DPP4. Although these drugs appear
which show an association with diabetic cardiomy- effective in treating diabetes in people without con-
opathy. comitant heart failure, in patients with heart failure
there are some limitations. The classic example is
MRI (magnetic resonance imaging) metformin, which has been previously contraindicat-
MFR (myocardial flow reserve) is not routinely as- ed in heart failure because of the risk of lactic aci-
28
sessed in MPI(myocardial perfusion imaging) stud- dosis. However in clinical practice and use, it turns
ies,but it has been hypothesized to affect test ac- out that the risk of lactic acidosis associated with
curacy when assessing disease severity by coronary metformin in people with diabetes and heart failure is
vessel Lumenography.MRIis an emerging diagnostic not so great. Additionally, metformin can upregulate
technique that can both perform MPI and assess cardiomyocyte autophagy, which plays an important
MFR. Furthermore, MRI is also a very useful tool to role in the prevention of diabetic cardiomyopathy in
animal models. Metformin has also been reported

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