diabetes affects almost every tissue in the body and causes significant organ dysfunction that results in diabetes - related morbidity and mortality .
coronary artery disease is the leading cause for the increased cardiovascular morbidity and mortality in diabetes , and atherosclerosis of the coronary vessels is its initial pathogenetic mechanism .
coronary artery disease and hypertension can account for most of the myocardial abnormalities that occur in diabetes .
however , postmortem , experimental , and observational studies also provide evidence for a specific cardiomyopathy in diabetes , which may contribute to myocardial dysfunction in the absence of coronary artery atheroma .
this is also sustained by the fact that patients with diabetes , independently of the severity of coronary artery disease , have increased risk of heart failure in comparison with subjects without diabetes . in general diabetes
affects the heart in 3 ways : ( 1 ) coronary artery disease due to accelerated atherosclerosis ; ( 2 ) cardiac autonomic neuropathy ; and ( 3 ) diabetic cardiomyopathy ( dcp ) .
although there is high awareness among clinicians about the first two disease entities , diabetic cardiomyopathy is poorly recognized by most physicians .
dcp , first defined by rubler in 1972 , is characterized by the myocardial dysfunction in the absence of coronary artery disease , hypertension , or valvular heart disease .
it is associated with both type 1 and type 2 diabetes mellitus ( t1 dm and t2 dm ) . as in the case that we report here , dcp may be subclinical for a long time , before the appearance of clinical symptoms or signs .
we present the case of a 39-year - old man that was admitted in our clinic due to a stroke . according to its past medical history ,
the patient was diagnosed in the primary care setting with elevated blood glucose levels , about 8 months before the stroke .
the rest of his past medical history was free of any other diseases . according to the information we have , at that time the patient was given lifestyle advice on dietary and physical activity , by the primary care physician .
he was also strongly encouraged to lose weight as the patient had body mass index of 34 ( bmi = 34 ) .
unfortunately , there is no record of the specific glucose values identified at that time .
we do nt know also , the time period that this patient had deranged blood sugar levels , since , according to what he reported , he did nt have any medical blood tests done over the past 10 years . during his admission to the hospital , the patient was afebrile , well - oriented in time and space , with paresis of the right upper and lower limbs .
his arterial blood pressure was 140/90 mmhg , electrocardiogram ( ecg ) with sr and his pulse was regular .
his bmi at that time was the same with the bmi originaly calculated about 68 months ago .
his medical history was free of any other diseases , apart from the hyperglycemia mentioned earlier .
the computed tomography ( ct ) brain scan revealed an extensive ischemic infarct of the left parietal lobe in the supply zone of the left middle cerebral artery .
his biochemical tests results were : white blood cell count ( wbc ) = 9000/l , hematocrit value ( hct ) = 44,8% , serum glutamic oxaloacetic transaminase ( sgot ) = 33u / l , serum glutamic - pyruvic transaminase ( sgpt ) = 21u / l , -gt : 53u / l , blood glucose level : 187 mg / dl . during the 2 day of hospitalization we performed an ecg .
we found an enlarged left atrium , an enlarged hypokinetic left ventricle with an ejection fraction of 30% and a large thrombus in it as well as an enlarged right ventricle .
warfarin was added to his drug therapy , that already included antiplatelet agents . during his stay in the hospital ,
the diagnosis of dm for the first time was made and his glycosylated hemoglobin level ( hba1c ) was 10.42% .
the patient followed a stable clinical course with a progressive improvement in his motor functions .
he is now on motor physiotherapy and a regular medical follow - up for his diabetes , his heart failure and the stroke .
dcp is defined as the cardiovascular damage present in diabetes patients , which is characterized by myocardial dilatation and hypertrophy , as well as a decrease in the systolic and diastolic function of the left ventricle , and its presence is independent of the coexistence of ischemic heart disease or hypertension . as in the case of our patient , dcp may be subclinical for a long time , before the appearance of clinical symptoms or signs .
various proposed mechanisms include metabolic disturbances , insulin resistance , microvascular disease , alterations in the renin - angiotensin system ( ras ) , cardiac autonomic dysfunction and myocardial fibrosis .
chronic hyperglycemia is thought to play a central role in the development of dcp , although multiple complex mechanisms and an interplay of many molecular and metabolic events within the myocardium and plasma contribute to the pathogenesis .
the main metabolic abnormalities in diabetes are hyperglycemia , hyperlipidemia and inflammation , all of which stimulate generation of reactive oxygen or nitrogen species that cause most of the diabetic complications , including diabetic nephropathy and dcp .
several adaptive responses caused by these metabolic abnormalities finally result in cardiac dysfunction and heart failure .
however , proper treatment of diabetes and its metabolic abnormalities in the primary care setting reduces the rates of dcp , myocardial infarction , and associated cardiovascular death .
since dcp is now known to have a high prevalence in the asymptomatic diabetic patient , screening for its presence at the earliest stage of development would be appropriate in order to prevent the progression to congestive heart failure and further significant complications . as this high - risk diabetic population is constanly rising , increasing the awareness of physicians for the serious metabolic complications of diabetes , especially in the primary care setting , will help in taking appropriate and early action towards the prevention of full - blown disease and decreasing disability and mortality .
 diabetic cardiomyopathy ( dcp ) is defined as the cardiovascular damage present in diabetes patients , which is characterized by myocardial dilatation and hypertrophy , as well as a decrease in the systolic and diastolic function of the left ventricle , and its presence is independent of the coexistence of ischemic heart disease or hypertension . as in the case of the patient that we present here , dcp may be subclinical for a long time , before the appearance of serious clinical symptoms , signs and complications . 
 dcp is poorly recognized by most physicians . 
 currently , there is no specific treatment for this pathologic entity . 
 however , proper treatment of diabetes and its metabolic abnormalities in the primary care setting reduces the rates of this serious metabolic complication of diabetes . as this high - risk diabetic population is constantly rising , increasing the awareness of physicians for the serious metabolic complications of diabetes , especially in the primary care setting , will help in taking appropriate and early action towards the prevention of full -blown disease and decreasing disability and mortality . 
Introduction
Case Report
Discussion