Feature-tracking global longitudinal strain has prognostic value in heart failure patients with diabetes

Background Heart failure (HF) and diabetes epidemiologically share a bidirectional relationship, with each increasing the incidence and worsening the prognosis of the other. Global longitudinal strain (GLS) measured by feature tracking cardiovascular magnetic resonance (CMR) has prognostic value in HF. However, this has not been established in HF patients with diabetes. Objectives This study aimed to assess the prognostic value of GLS in HF patients with diabetes. Methods Consecutive patients (n=315) with HF from six tertiary cardiac centres in Singapore underwent CMR at 3T, including GLS, late gadolinium enhancement (LGE), native T1 mapping, and extracellular volume fraction (ECV) mapping. The primary outcome was a composite of all-cause mortality or HF hospitalisation. Results Compared to those without diabetes (n=156), the diabetes group (n=159) had a higher prevalence of LGE (76 vs 60%, p<0.05), higher T1 (1285±42 vs 1269±42ms, p<0.001) and higher ECV (30.5±3.5 vs 28.8±4.1%, p<0.001). Compared to those without diabetes, diabetes conferred a worse prognosis (log rank chi-squared 12, p<0.001, 74 events, median [interquartile range] 23 [18-24] months follow-up). In multivariable Cox regression models in the diabetes group, GLS was prognostic (hazard ratio 1.15 [95% confidence interval 1.06-1.25], p<0.001). When stratified by both diabetes status and median absolute GLS (9.9%), patients with diabetes and poorer GLS had the worst prognosis (log-rank chi-squared 31, p<0.001). Conclusion Compared to heart failure patients without diabetes, those with diabetes have worse CMR markers of fibrosis and adverse prognosis. GLS is a powerful and independent prognostic marker in heart failure patients with diabetes. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement The ATTRaCT study was supported by research grants from A*STAR Biomedical Research Council ATTRaCT program \[SPF2014/003, SPF2014/004, SPF2014/005\] (A*STAR, Singapore). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethics approval was obtained from the local Centralized Institutional Review Board in Singapore, and all participants provided written informed consent. The study was conducted in accordance with the principles of the Declaration of Helsinki. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data that support the findings of this study are included in this article or available from the corresponding author upon reasonable request.