Subclinical cardiac involvement during diabetic ketoacidosis at type 1 diabetes onset in youth: biomarker elevation, altered diastolic filling, and reduced global longitudinal strain: a prospective cohort study

Abstract Background Diabetic ketoacidosis (DKA) may be associated with cardiac involvement. Increased cardiac biomarkers and abnormalities in cardiac function were mainly reported in adults with type 1 diabetes (T1D). Pediatric data are lacking. This study therefore assessed cardiac biomarker alterations and echocardiographic changes, including strain analysis, in children with diabetic ketoacidosis at the onset of type 1 diabetes. Research design and methods In this prospective, observational, cohort study, patients < 18 years with T1D onset were consecutively enrolled at a single center from January 2024 to March 2025 and classified as DKA or non-DKA. Cardiac biomarkers (troponin I, NT-proBNP) were measured before and 24 h after therapy initiation in all patients, and additionally at 48 and 72 h in those with DKA. Echocardiography, including speckle-tracking strain analysis, was performed after 24 h in both groups and after 6 days in the DKA group. Results Eighty-one patients were included (60% male; median age 9.8 years [5.2–14.1]); 43 (53.1%) had DKA. Troponin I and NT-proBNP were significantly higher in the DKA group at baseline (troponin I: 5.7 [4.1–10.8] vs. 3.9 [3.9–4.6] ng/L, p < 0.001; NT-proBNP: 87.0 [41.0–231.0] vs. 40.0 [16.8–69.0] ng/L, p = 0.002) and remained elevated at 24 h. Echocardiography showed lower E/A ratios, higher peak a′-wave velocities, and a significantly reduced left ventricular global longitudinal strain (GLS) in the DKA group (− 19.2 [− 20.4 to − 18.1] vs. − 21.5 [− 23.0 to − 18.9], p = 0.029), with most values within the normal range. In multivariable analysis, lower bicarbonate (indicating greater DKA severity) was independently associated with higher troponin I and NT-proBNP, and younger age with higher NT-proBNP. Conclusions In children with T1D, DKA at onset is associated with subclinical cardiac involvement, reflected by elevated cardiac biomarkers, altered diastolic filling parameters, and reduced left ventricular GLS. These findings indicate myocardial stress during the acute phase of DKA; whether they carry prognostic significance requires studies with longer-term follow-up. Trial registration The study was registered in the German Clinical Trial Register (DRKS00032719).