What is the next step in management for an asymptomatic patient with hypertension (high blood pressure) and type 2 diabetes mellitus (DM2) who has an electrocardiogram (ECG) showing poor R wave progression?

Management of Asymptomatic Poor R Wave Progression in a Patient with Hypertension and Type 2 Diabetes

In an asymptomatic patient with hypertension and type 2 diabetes showing poor R wave progression on ECG, proceed directly to echocardiography to evaluate for left ventricular hypertrophy, assess diastolic function, and rule out silent myocardial infarction or diabetic cardiomyopathy. 1, 2

Rationale for Echocardiography

• Poor R wave progression has multiple potential causes in this clinical context, including anterior myocardial infarction, left ventricular hypertrophy (common with hypertension), right ventricular hypertrophy, or a normal variant with diminished anterior forces. 3

• In diabetic patients specifically, poor R wave progression correlates with left ventricular diastolic dysfunction and may be an early sign of diabetic cardiomyopathy, with studies showing these patients have significantly lower mitral annulus Em velocities, higher Tei indices, and more prevalent LV relaxation abnormalities. 4

• The 2019 ESC guidelines explicitly recommend a resting ECG in patients with diabetes and hypertension, and when ECG abnormalities are present (as in this case), echocardiography becomes indicated to assess for hypertension-mediated organ damage. 1, 5

• Echocardiography is mandatory when ECG shows abnormalities to detect left ventricular hypertrophy, assess cardiac function, and evaluate for structural heart disease. 6, 5

What to Assess on Echocardiography

• Evaluate left ventricular mass index (abnormal if >95 g/m² in women or >115 g/m² in men) and relative wall thickness (abnormal if >0.42) to diagnose and quantify left ventricular hypertrophy. 1

• Assess diastolic function parameters including septal e' velocity (<8 cm/sec is abnormal), lateral e' velocity (<10 cm/sec is abnormal), left atrial volume index (≥34 mL/m² is abnormal), and E/e' ratio (≥13 suggests elevated filling pressures). 1

• Examine for regional wall motion abnormalities that would suggest prior myocardial infarction, as poor R wave progression can indicate anterior MI even without Q waves. 3, 7

• Calculate left ventricular ejection fraction to rule out heart failure with reduced ejection fraction (HFrEF), though a normal ECG has a 99.3% negative predictive value for excluding HFrEF in diabetic patients. 2

Why Routine Coronary Screening is NOT Recommended

• The 2020 ADA guidelines explicitly state that in asymptomatic patients, routine screening for coronary artery disease is not recommended as it does not improve outcomes as long as atherosclerotic cardiovascular disease risk factors are treated. 1

• Multiple randomized controlled trials (DIAD, DYNAMIT, FACTOR-64, DADDY-D) demonstrated that screening asymptomatic diabetic patients for coronary disease did not reduce major cardiac events, with annual event rates remaining low (0.6-1.9%) regardless of screening strategy. 1

• The 2019 ESC guidelines confirm that routine screening of CAD in asymptomatic diabetes is not recommended, though stress testing or CT coronary angiography may be considered in very high-risk individuals with peripheral arterial disease, high coronary artery calcium score, proteinuria, or renal failure. 1

Optimize Medical Management Regardless of Imaging Results

• Intensify cardiovascular risk factor control with target blood pressure 120-130 mmHg systolic (or 130-140 mmHg if age >65 years), LDL-cholesterol to target, and HbA1c optimization. 1

• Initiate or optimize ACE inhibitor or ARB therapy, which is recommended in patients with diabetes and hypertension to reduce cardiovascular events and provide renal protection. 1, 8

• Consider adding an SGLT2 inhibitor with demonstrated cardiovascular benefit (empagliflozin, canagliflozin, or dapagliflozin) or a GLP-1 receptor agonist (liraglutide or semaglutide), as these are recommended in type 2 diabetes with established atherosclerotic cardiovascular disease or multiple risk factors. 1

• Assess for microalbuminuria annually to identify patients at risk for renal dysfunction and high cardiovascular risk, and ensure statin therapy is prescribed unless contraindicated. 1

Clinical Pitfalls to Avoid

• Do not dismiss poor R wave progression as a benign finding in diabetic patients, as it correlates with diastolic dysfunction and predicts worse outcomes, with hazard ratios for cardiovascular disease or death increasing from 1.85 with normal ECG to 3.84 with abnormal ECG in heart failure patients. 2, 4

• Do not proceed to invasive coronary angiography or stress testing without first obtaining echocardiography, as the structural and functional information from echo will guide whether further ischemia evaluation is warranted. 1

• Recognize that 56% of patients with poor R wave progression do NOT have anterior myocardial infarction on angiography, making echocardiography essential to differentiate between MI, left ventricular hypertrophy, and other causes. 7