Diabetic cardiomyopathy: An expression of stage B heart failure with preserved ejection fraction

Heart failure is now recognized as a progressive disease in which patients transition through the stages of being at risk of heart failure (stage A), to asymptomatic structural heart disease (stage B), to clinical manifestations of heart failure (stage C) and finally end-stage or refractory heart failure (stage D). This review outlines the key role of diabetes mellitus as a stage A risk factor for heart failure with preserved ejection fraction, and asymptomatic diabetic cardiomyopathy, referring to the presence of left ventricular diastolic dysfunction in diabetic patients without coronary artery disease, hypertension or other potential aetiologies, as an expression of stage B heart failure with preserved ejection fraction at high risk of transitioning to symptomatic stage C heart failure with preserved ejection fraction. The data presented call for better recognition of the unique phenotype of diabetic cardiomyopathy with preserved ejection fraction and elevated diastolic stiffness as a manifestation of stage B heart failure with preserved ejection fraction that should be targeted for risk management and preventive strategies.