Diabetic Cardiomyopathy: Current and Future Therapies. Beyond Glycemic Control

Abstract

Diabetes mellitus and the associated complications represent a global burden on human health and economics. Cardiovascular diseases are the leading cause of death in diabetic patients, who have a 2–5 times higher risk of developing heart failure than age-matched non-diabetic patients, independent of other comorbidities. Diabetic cardiomyopathy is defined as the presence of abnormal cardiac structure and performance in the absence of other cardiac risk factors, such coronary artery disease, hypertension, and significant valvular disease. Hyperglycemia, hyperinsulinemia, and insulin resistance mediate the pathological remodeling of the heart, characterized by left ventricle concentric hypertrophy and perivascular and interstitial fibrosis leading to diastolic dysfunction. A change in the metabolic status, impaired calcium homeostasis and energy production, increased inflammation and oxidative stress, as well as an accumulation of advanced glycation end products are among the mechanisms implicated in the pathogenesis of diabetic cardiomyopathy. Despite a growing interest in the pathophysiology of diabetic cardiomyopathy, there are no specific guidelines for diagnosing patients or structuring a treatment strategy in clinical practice. Anti-hyperglycemic drugs are crucial in the management of diabetes by effectively reducing microvascular complications, preventing renal failure, retinopathy, and nerve damage. Interestingly, several drugs currently in use can improve cardiac health beyond their ability to control glycemia. GLP-1 receptor agonists and sodium-glucose co-transporter 2 inhibitors have been shown to have a beneficial effect on the cardiovascular system through a direct effect on myocardium, beyond their ability to lower blood glucose levels. In recent years, great improvements have been made toward the possibility of modulating the expression of specific cardiac genes or non-coding RNAs in vivo for therapeutic purpose, opening up the possibility to regulate the expression of key players in the development/progression of diabetic cardiomyopathy. This review summarizes the pathogenesis of diabetic cardiomyopathy, with particular focus on structural and molecular abnormalities occurring during its progression, as well as both current and potential future therapies.

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“…Diabetic cardiomyopathy is a common complication of diabetes mellitus, which is defined as adverse changes in myocardial structure and function in the absence of other cardiac risk factors including coronary artery disease or hypertension [71]. Diabetic cardiomyopathy is characterized by increased myocardial fibrosis and stiffness, with this being associated with the impaired diastolic function, late systolic dysfunction resulting in the inability of the heart to pump enough blood through the body, a state called heart failure [72].…”

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“…As such, individuals with diabetes have a 20%-40% higher incidence of heart failure [1] and a 33% higher risk of hospitalization [2]. Separate from these aforementioned cardiovascular comorbidities, there exists a specific diabetic cardiomyopathy characterized in part by cardiomyocyte hypertrophy and interstitial cardiac fibrosis [3][4][5]. This concept was originally identified by Rubler et al [6] in 1972, after case study observations of cardiomegaly, cardiac fibrosis, small vessel alterations, and heart failure in diabetic individuals.…”

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“…A combination of metabolic abnormalities is acknowledged to be responsible for enhanced susceptibility of diabetic individuals to myocardial damage. For example, in type 2 diabetes (T2D), the predominant form of diabetes that is associated with dyslipidaemia and enhanced arterial atherosclerotic buildup has been directly connected with endothelial dysfunction and subsequent increased risk of heart failure . The characteristic features of diabetic dyslipidaemia include elevated plasma triglyceride and low‐density lipoprotein (LDL) concentrations, and reduced high‐density lipoprotein (HDL) levels.…”