Impact of Comprehensive Metabolic Optimization on Myocardial steatosis and Cardiac Remodeling in newly diagnosed type 2 diabetes: a longitudinal study

Background Cardiac remodeling is common in individuals with type 2 diabetes (T2D) and may be influenced by both glycemic and metabolic factors. On the other hand, myocardial steatosis, a hallmark of diabetic cardiomyopathy, has been inconsistently linked to glycemic control. This study aimed to evaluate the impact of comprehensive metabolic optimization—targeting improvements in both glycemic control and adiposity— on myocardial triglyceride content (MTGC) and cardiac remodeling in newly diagnosed. Methods Twenty adults with newly diagnosed T2D underwent a 12-month standardized metabolic optimization protocol including insulin, metformin, and empagliflozin therapy, alongside nutritional and lifestyle counseling. Cardiac magnetic resonance imaging (CMR) and proton magnetic resonance spectroscopy ( ¹ H-MRS) were performed at baseline and after 12 months to assess cardiac structure, function, and myocardial triglyceride content (MTGC). Analyses assessed longitudinal changes and explored associations among clinical, biochemical, and imaging parameters. Results Participants (mean age 54.8 ± 9 years, 72.3% male) achieved significant reduction in HbA1c, body mass index (BMI) and waist circumference (WC) after 12 months of glycemic optimization. No significant changes in MTGC were found at follow up (0.52% [0.25–1.44] vs 1.05% [0.43–3.06]; p = 0.23). In contrast, CMR parameters showed favorable remodeling with improved left ventricular ejection fraction Left Ventricle(LV) Ejection Fraction (59.0% [54.8–61.5] vs 63.1%[56.9–66.3], p = 0.01) and reduced ventricular volumes (LV) End-systolic volume (29.9 mL/m2 [26.4–35.1] vs 27.3 mL/m2 [22.5–31.7]; p = 0.007), LV mass (46.1 g/m2 [35.1–54.2] vs 49.5 [39.5–54.3], p = 0.006), right ventricular (RV) End-systolic volume (30.6 mL/m2 [25.9–35.7] vs 28.7 mL/m2 [25.5–32.6], p = 0.02) and RV End-diastolic volume (76.5 mL/m2 [64.6–82.4] vs 72.4 mL/m2 [66.1–77.7], p = 0.03). No associations were found between HbA1c improvement and MTGC or CMR parameters. Changes in BMI and WC strongly correlated with improved left atrial strain (ρ = − 0.78 and − 0.77; p < 0.001), whereas WC correlated with LV End-diastolic volume (ρ = -0.59, p = 0.024). Conclusions In newly diagnosed T2D, 12 months of comprehensive metabolic optimization improved cardiac remodeling parameters without altering myocardial steatosis. The cardiac benefits observed were closely related to reductions in adiposity rather than glycemic normalization, emphasizing the importance of weight management as a key therapeutic target for early prevention of diabetic cardiomyopathy