Figure 1 illustrates the flow of participants in the present study where, out of 450 diabetics who responded to the call launched at Center ADIC, 20 were not included in the study for the following reasons: not being a resident of Goma, followed for IC and presenting with visible pregnancy. Of the 430 diabetics included in the study, 22 were excluded for not having carried out an ECG and the entire assessment. At the end of the study, the sample analyzed is 408 (Figure 1).
Table 1 compares the general characteristics of the study population between the types of diabetes (type 1 vs type 2). For all of the asymptomatic diabetics, a significant difference between the two groups was observed for age, blood pressure components (SBP, DBP, PP and MBP), OAD and insulin intake; and eGFR. (Table 1)
Table 1. General characteristics of the study population
Variables
|
All patients
n=408
|
DM t1
n=120
|
DM t2
n=288
|
p
|
Age (years)
|
53.9±14.5
|
37.8±10.8
|
60.6±9.7
|
<0.001
|
Age ≥40 years
|
339(83.1)
|
53(44.2)
|
286(99.3)
|
<0.001
|
Sex
|
|
|
|
0.483
|
Male
|
169(41.4)
|
49(40.8)
|
120(41.7)
|
|
Female
|
239(58.6)
|
71(59.2)
|
168(58.3)
|
|
Dyspnea NYHA
|
|
|
|
0.143
|
Class I
|
331(81.1)
|
93(77.5)
|
238(82.6)
|
|
Class II
|
77(18.9)
|
27(22.5)
|
50(17.4)
|
|
DM duration (year)
|
8.0 (7.0-9.0)
|
7.0 (6.0-9.0)
|
8.0 (6.0-9.0)
|
0.426
|
SBP (mmHg)
|
137.4±25.9
|
123.3±22.6
|
143.2±24.9
|
<0.001
|
DBP (mmHg)
|
84.1±13.5
|
79.7±13.3
|
85.9±13.1
|
<0.001
|
MAP (mmHg)
|
101.9±16.4
|
94.2±15.4
|
105.0±15.8
|
<0.001
|
MP (mmHg)
|
53.3±18.4
|
43.5±15.2
|
57.3±18.1
|
<0.001
|
HR (bpm)
|
82.1±12.8
|
83.9±13.1
|
81.4±12.6
|
0.063
|
BMI (Kg/m²)
|
27.7±5.7
|
26.1±6.1
|
28.3±5.3
|
<0.001
|
Treatment
|
|
|
|
|
IEC
|
10(2.5)
|
1(0.8)
|
9(3.1)
|
0.155
|
Anti Ca
|
35(8.6)
|
2(1.7)
|
33(11.5)
|
<0.001
|
ARA II
|
28(6.9)
|
4(3.3)
|
24(8.3)
|
0.048
|
BB
|
23(5.6)
|
4(3.3)
|
19(6.6)
|
0.142
|
Diuretic
|
35(8.6)
|
5(4.2)
|
30(10.4)
|
0.026
|
ADO
|
272(66.7)
|
40(33.3)
|
232(80.6)
|
<0.001
|
Insulin
|
133(32.6)
|
73(60.8)
|
60(20.8)
|
<0.001
|
As Junior
|
13(3.2)
|
1(0.8)
|
12(4.2)
|
0.066
|
Hypolipidemic
|
5(1.2)
|
1(0.8)
|
4(1.4)
|
0.540
|
Fasting glucose mg/dL
|
172.0 (163.0-179.5)
|
176.0 (137.5-211.0)
|
172.0 (162.0-179.0)
|
0.684
|
HbA1C (%)
|
9.1 (8.8-9.4)
|
9.3 (8.8-10.0)
|
9.0 (8.7-9.3)
|
0.136
|
BNP (pg/mL)
|
44.6 (41.9-48.9)
|
44.1 (37.9-50.4)
|
45.6 (42.0-50.0)
|
0.184
|
LDLc (mg/dL)
|
112.7 (105.7-119.7)
|
104.9 (94.6-120.2)
|
115.9 (106.9-123.3)
|
0.346
|
Triglyceride (mg/dL)
|
96.1 (89.5-103.6)
|
85.2 (71.4-96.1)
|
101.3 (92.5-107.4)
|
0.414
|
HDLc (mg/dL)
|
50.4 (49.5-52.6)
|
49.6 (47.9-53.5)
|
51.7 (49.6-53.0)
|
0.063
|
TC (mg/dL)
|
186.1 (182.5-194.7)
|
179.9 (167.8-200.9)
|
186.2 (182.8-197.5)
|
0.066
|
Creatinine (mg/dL)
|
0.9 (0.7-1.0)
|
0.8 (0.7-0.9)
|
0.9 (0.8-1.1)
|
0.008
|
eGFR (ml/min/1.73m²)
|
94.4 (91.5-99.1)
|
112.0 (108.5-117.5)
|
88.9 (85.9-91.8)
|
<0.001
|
Abbreviations: DM: diabetes mellitus, SBP: Systolic Blood Pressure, DBP: Diastolic Blood Pressure, MBP: Mean Blood Pressure, PP: Pulse pressure, HR: Heart Rate, BMI: BMI: Body Mass Index; HbA1c: Glycosylated hemoglobin, eGFR: Estimated glomerular filtration rate, NYHA: New York Heart Association; BNP: Bread Natriuretic Peptide; LDL-c:Low density lipoproteins cholesterol; HDL-c: High Density lipoproteins cholesterol; TC: Total Cholesterol.
The cumulative frequency of PP was presented in Figure 2 and it is noted that the pulse pressure values were concentrated between 45 mmHg and 65 mmHg. The average values noted were 53.3 ± 18.4 mmHg for all diabetics, 43.5 ± 15.2 mmHg for type 1 diabetics and 57.3 ± 18.1 mmHg for diabetes mellitus type 2 (Figure 2).
Incidence of heart failure
Of a total of 408 diabetic patients examined, 122 presented a risk of heart failure, a frequency of 29.98% (Figure 3).
By comparing the subjects with incidence of IC to those without incidence of IC (table 2), it can be seen that the patients with incidence of IC included a greater proportion of patients aged over 40, women, subjects with SBP≥140 mmHg, PP≥65 mmHg and eGFR<60 ml/min/1.73m² (Table 2).
Table 2. General characteristics of the population according to the incidence of heart failure
Variables
|
No Incidence HF
n=288
|
Incidence HF
n=120
|
p
|
Age. Years
|
52.4±13.9
|
57.5±15.2
|
0.001
|
Age ≥ 40 years
|
235(81.6)
|
104(86.7)
|
0.045
|
female sex
|
159(55.2)
|
80(66.7)
|
0.021
|
DM Duration years
|
8.0 (6.0-9.0)
|
9.0 (6.0-10.)
|
0.409
|
Hypertension
|
121(42.0
|
57(47.5
|
0.182
|
DM t2
|
197(68.4
|
91(75.8
|
0.082
|
SBP≥140mmHg
|
108(37.5
|
59(49.2
|
0.019
|
DBP≥90mmHg
|
88(30.6
|
38(31.7
|
0.456
|
SBP mmHg
|
134.6±23.0
|
143.9±30.9
|
0.001
|
DBP mmHg
|
83.7±12.7
|
85.0±15.1
|
0.399
|
MBP mmHg
|
100.7±14.9
|
104.6±19.2
|
0.028
|
PP mmHg
|
50.9±16.4
|
58.9±21.4
|
<0.001
|
HR bpm
|
82.2±12.8
|
82.0±13.0
|
0.931
|
BMI Kg/m2
|
28.1±5.5
|
26.6±6.0
|
0.019
|
PP≥65mmHg
|
72(25.0)
|
50(41.7)
|
0.001
|
Blood glucose mg/dL
|
195.8±95.9
|
192.2±95.9
|
0.723
|
HbA1C %
|
9.2±2.0
|
9.4±2.1
|
0.546
|
Hb1AC ≥7%
|
212(87.2
|
85(87.6
|
0.541
|
Creatinine mg/dL
|
0.86 (0.80-0.90)
|
0.90 (0.80-0.90)
|
0.290
|
eGFR<60 ml/min/1.73m²
|
27(9.4
|
19(15.8
|
0.024
|
eGFR ml/min/1.73m²
|
96.3 (93.0-102.1)
|
89.6 (84.1-94.6)
|
0.012
|
Abbreviations: DM: diabetes mellitus, SBP: Systolic Blood Pressure, DBP: Diastolic Blood Pressure, MBP: Mean Blood Pressure, PP: Pulse pressure, HR: Heart Rate, BMI: BMI: Body Mass Index; HbA1c: Glycosylated hemoglobin, eGFR: Estimated glomerular filtration rate.
Table 3. Areas under the curve of the different blood pressure components
Pression
|
AUC
|
SE
|
95%CI
|
SBP, mmHg
|
0.831
|
0.028
|
0.777-0.885
|
DBP, mmHg
|
0.619
|
0.041
|
0.539-0.699
|
MBP, mmHg
|
0.742
|
0.035
|
0.674-0.811
|
PP, mmHg
|
0.873
|
0.022
|
0.829-0.916
|
Abbreviations. SBP:Systolic Blood Pressure, DBP: Diastolic Blood Pressure, MBP: Mean Blood Pressure, PP: Pulse pressure, AUC: Area Under curve, SE: Standard error; CI: confidence interval
Analysis of the ROC curve (Figure 4 and Table 3) showed that PP was the most important component of AP associated with a high risk of subsequent HF [AUC = 0.873; 95% CI: 0.829-0.916] compared to SBP (AUC=0.831; 95% CI 0.777-885], PAD (AUC= 0.619; 95% CI 0.539-0.699] and MAP (AUC=0.742; 95% CI: 0.674- 0.811].
In a simple linear regression analysis (Table 4) age, systolic blood pressure, pulse pressure and BMI were positively associated with variation in BNP, while gender and eGFR were negatively associated with BNP (Table 4).
Table 4. Linear correlation between BNP and independent variables
Variable
|
Spearman's Rho
|
p-value
|
Age, years
|
0.196
|
<0.001
|
Sex
|
-0.122
|
0.014
|
DM duration (years)
|
0.058
|
0.243
|
SBP mmHg
|
0.112
|
0.024
|
DBP mmHg
|
-0.031
|
0.538
|
MBP, mmHg
|
0.040
|
0.422
|
PP, mmHg
|
0.290
|
<0.001
|
HR, bpm
|
-0.047
|
0.342
|
BMI, Kg/m2
|
0.146
|
0.003
|
Fasting glucose mg/dL
|
-0.031
|
0.528
|
eGFR, ml/min/1.73m²
|
-0.186
|
<0.001
|
Abbreviations: DM: diabetes mellitus, SBP: Systolic Blood Pressure, DBP: Diastolic Blood Pressure, MBP: Mean Blood Pressure, PP: Pulse pressure, HR: Heart Rate, BMI: BMI: Body Mass Index; eGFR: Estimated glomerular filtration rate.
The determinants of HF incidence in univariate and multivariate analysis appear in Table 5. In univariate logistic regression analysis, age ≥ 40 years, female gender, SBP≥140 mmHg, PP≥65 mmHg, BMI ≥25 Kg/m² and eGFR<60 ml/min/1.73m² emerged as determinants of HF incidence. After adjusting for all these variables in a multiple logistic regression, age≥40 years (aOR: 2.02, 95% CI: 1.03-3.04) (p=0.024), female gender (aOR: 2.00, 95% IC: 1.24- 3.25) (p=0.005), PP≥65 mmHg (aOR: 2.63, 95% CI: 1.83-3.99) (p<0.001) and eGFR<60 mmHg (aOR: 1.99, 95% CI: 1.09-3.00) (p =0.037) were the independent risk factors associated with the incidence of HF in diabetics (Tableau 5).
Table 5. Factors associated with the incidence of heart failure in diabetics
Variable
|
Univariate analysis
|
|
Multivariate analysis
|
p
|
OR (95%CI)
|
p
|
aOR (95%CI)
|
Age ≥40 years
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.001
|
2.03 (1.01-3.04)
|
|
0.024
|
2.02 (1.03-3.04
|
Female sex
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.003
|
1.92 (1.39-3.96)
|
|
0.005
|
2.00 (1.24-3.25)
|
SBP≥140mmHg
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.030
|
1.61 (1.05-2.48)
|
|
0.862
|
1.06 (0.56-1.99)
|
PP≥65mmHg
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.001
|
2.14 (1.37-3.36)
|
|
<0.001
|
2.63 (1.83-3.99)
|
BMI <25kgm2
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.019
|
0.95 (0.92-0.99)
|
|
0.211
|
0.92 (0.88-1.96)
|
eGFR<60ml/min/1.73m²
|
|
|
|
|
|
No
|
|
1
|
|
|
1
|
Yes
|
0.013
|
2.18 (1.07-3.42)
|
|
0.037
|
1.99 (1.09-3.00)
|
AbbreviationsSBP: Systolic Blood Pressure, PP: Pulse pressure, BMI: BMI: Body Mass Index; eGFR: Estimated glomerular filtration rate; aOR: adjusted Odd Ratio; CI: Confidence Interval.