1. P-wave Dispersion and Diastolic Function in Pubertal Type 1 Diabetic Children P6:T1 Maha Amin1, Yasser Hussein Kamel2, Amany Ibrahim1, Fawzia Salim Ali Hamad 1 The Pediatric Department, Diabetes Endocrine and Metabolism Pediatric Unit (DEMPU), Children Hospital, Faculty of Medicine, Cairo University 2 The Pediatric Department, Pediatric Cardiology Unit, Children Hospital, Faculty of Medicine, Cairo University Introduction Patients and Methods Abstract Results References Conclusion Objective Background: Diastolic dysfunction is often the first manifestation of diabetic cardiomyopathy preceding the systolic damage and clinical signs of heart failure and which could be detected by echocardiography. In the adult patient who has diastolic dysfunction an increased value of P-wave dispersion (PD) has been found. The increase in the P-wave dispersion in diabetic adolescents was discussed in few studies. Objective: To show the effect of chronic hyperglycemia in type 1 diabetic adolescents on PD & diastolic function & to correlate the results to diabetes duration and complications. Subject and Method: Cross sectional, case control study included 50 pubertal adolescents (28 ) males, ( 22) females with T1D of more than 5 years duration with age ranging from 9.5-19 years matched to 30 healthy control of same age and sex. All patients and controls were subjected to clinical examination, anthropometric measurements, pubertal assessment, lipid profile, echocardiography and 12 leads ECG. Albumin creatinine ratio (Alb/creat) and fundus examination were done only for the patients. Results: Diastolic dysfunction of both right and left ventricles and increased PD were found in patients. When correlating PD to echo parameters, a positive correlation was found between PD and LVEED (r = 0.3, p= 0.04). Significant negative correlation was found between PD and both of A mitral and IVRT (r = -0.32, p=0.03 and r =-0.38, p= 0.01, respectively. Significant positive correlation was found between the duration of diabetes and IVRT (r =0.39, p = 0.02) & significant negative correlation between the duration and E mitral and E/A ratio mitral (r = -0.38, p =0.01, and r = -0.29, p = 0.04, respectively). No correlation found to glycemic control, lipid profile, or Alb/ creat. Significant positive correlation between LDL level and Alb/creat ratio(r =0.32, p =0.02). Conclusions: Increased PD in T1D patients make them prone to paroxysmal AF, diastolic dysfunctions are present in T1D patients and should be screened early so not to progress to diabetic heart failure. In T1D, the heart is subjected to a variety of pathological insults including accelerated atherosclerosis, cardiac autonomic neuropathy and possibly intrinsic cardiomyopathy. Diabetic cardiomyopathy (DC) has been proposed as diabetes specific complication. The most important mechanisms of DC are probably metabolic disturbances, microangiopathy, and myocardial fibrosis (1). Diastolic dysfunction is often the first manifestation of DC preceding the systolic damage and clinical signs of heart failure. Diastolic dysfunction results in an increased value of P-wave dispersion (PD). PD is a measure of heterogeneity of atrial refractoriness. In T1D, diastolic dysfunction without any cardiac disorder as an early finding of myocardial disease was reported (2). The increase in PD is a known electrophysiologic marker for the prediction of paroxysmal AF, making cardiac rhythm disorders liable to occur in patients with T1D. AF may be relatively common in diabetic patients and should be regarded as a marker of adverse outcome promoting aggressive management of all risk factors (3). To show the effect of chronic hyperglycemia in type 1 diabetic children on P-wave dispersion (PD) & diastolic function and to correlate the results with glycemic control, diabetes duration and complications. A Cross-sectional, case-control, prospective study included 50 children with T1D attending the outpatient DEMPU clinic and they were compared to 30 healthy controls age and sex matched. Patients were subjected to: A- History taking including: age and age of onset of diabetes and its duration. B- Examination including anthropometric measurement : Weight, Height & BMI and their SDS, and Pubertal assessment according to Tanner stages. Cardiac examination to detect any structural cardiac abnormality & blood pressure measurement. Tests reflecting sympathetic damage: (Blood pressure response to standing & Blood pressure response to sustained handgrip). C- Retrospective laboratory data were taken from patient files, Complete blood count, HbA1c, Lipid profile, Screening for microalbuminuria which is determined by albumin/ creatinine ratio. Mean for last 3 month SBGM if available. D- Ophthalmological examination. ECG electrocardiography 12 lead to show the p-wave dispersion and conventional echocardiography. Increased PD makes T1D patients prone to paroxysmal atrial fibrillation. Diastolic dysfunctions are present in T1D patients and should be screened early, so not to progress to diabetic heart failure. Vigorous treatment of microalbuminuria may improve lipid profile as well as the kidney and the heart. Recommendations  ECG may be used as rapid, easy, cheap, affordable method to screen for risk of paroxysmal atrial fibrillation. PD can be used as an early marker to investigate for underlying still early diastolic dysfunction before it progress to frank CHF due to the presence of correlation between p wave & some of echocardiographic data.  ECG may be used to screen diabetic patient with diastolic dysfunction and recommended for echo investigation.  Although our study revealed RV dysfunction by conventional Echocardiography but we recommend TDI for both right as well as left ventricular dysfunction.  Lipid profile may be used as a marker for renal impairment.  Diagnosis of diastolic dysfunction is very important for early diagnosis, follow up, treatment, and prognosis in heart failure diabetic patients.  Careful blood glucose control is a critical defense against complication and is the path for the improvement to their quality of life.  As obesity is a modifiable cardiovascular risk factor, careful monitoring and management of weight gain should be emphasized in diabetes care. 1.Retnakaran R, Zinman B (2008): Type 1 diabetes, hyperglycaemia, and the heart. The Lancet. 371, 1790 – 99. 2.2. Freire CM, Moura AL, Barbosa Mde M, Machado LJ, Nogueira AI, Ribeiro-Oliveira A Jr (2007): Left ventricle diastolic dysfunction in diabetes: an update. Arq Bras Endocrinol Metabol; 51: 168–175. 3.3. Nichols GA, Reinier K, and Chugh SS (2009): Independent Contribution of Diabetes to Increased Prevalence and Incidence of Atrial Fibrillation.Diabetes Care; 32: 1851–1856. Variables PatientsControls P-value MeanSDMeanSD Age (yrs)14.502.3913.482.31 0.07 Weight (SDS)-0.031.560.531.22 0.08 Height (SDS)-1.291.61-0.270.94 0.002 BMI (SDS)0.571.080.401.67 0.6 Hb (gm/dl)11.951.3712.621.03 0.02 HbA1 (%)8.682.145.360.68 0.0001 Total cholesterol (mg/dl)161.3334.77100.419.7 0.0001 LDL (mg/dl)100.533363.0719.36 0.0001 HDL (mg/dl)47.6310.7752.4311.11 0.06 Tg (mg/dl)77.6131.9369.2327.44 0.2 E mitral(m/sec)0.520.090.790.17 0.0001 A mitral(m/sec)0.50.120.470.11 0.1 E/A ratio1.120.451.620.3 0.0001 IVRT(mse)78.9411.5667.079.06 0.0001 LA(cm)2.560.142.520.32 0.4 LVEDD(cm)4.610.214.370.41 0.001 FS (%)34.33.3434.883.77 0.4 E tricuspid(m/sec)0.60.070.660.07 0.0001 A tricuspid(m/sec)0.390.090.490.13 0.0001 E/A ratio tricuspid1.570.271.440.4 0.1 IVRTTR(mse)68.841.3669.5 0.04 P max (ms)0.10.010.10.02 0.1 P min (ms)0.040.010.040.01 0.2 P D0.070.020.060.01 0.005 Table (1): Comparison between demographic, anthropometric, laboratory echocardiographic data, and p-wave characteristics, data of patients and controls Fig (1): correlation between A mitral and PD in T1D patients. Fig (2): correlation between IVRT and PD in T1D patients. Fig (3): correlation between LVEDD and PD in T1D patients. Fig (4): correlation between postural fall in blood pressure and E/A tricuspid in T1D patients. Fig (5): correlation between alb/cr ratio and LDL in T1D patients. Fig (6):comparison between LDLin T1D patients in relation to BMI. Fig (6):comparison between IVRT tricuspid in T1D patients in relation to BMI.