The relationship of diabetes mellitus (DM) with cardiovascular mortality and morbidity has been widely established. Diabetic cardiomyopathy (DBCM) has been increasingly recognized as the development of cardiac dysfunction accompanied by heart failure (HF) symptoms in the absence of obvious causes like coronary artery disease (CAD), hypertension (HTN) or valvular diseases. The objective of this review is to critically appraise the role of echocardiography in the diagnosis and prognostic stratification of DBCM. Echocardiography remains the first-line imaging modality due to its availability, repeatability, non-invasive nature and ability to assess structural and functional changes. Classical echocardiographic indices such as left ventricular hypertrophy and systolic and diastolic dysfunction assessment provide valuable information but they lack sensitivity, often remaining normal until advanced stages of DBCM. Recently developed echocardiographic modalities, including strain imaging, myocardial work indices and left atrial strain, may allow for earlier detection of subclinical myocardial dysfunction, having important prognostic implications. However, these advanced modalities require high imaging quality, expertise and standardization, being subject to technical and physio-logical limitations. Stress echocardiography, particularly exercise-based protocols, is an increasingly recognized, valuable tool for unmasking exertional abnormalities in filling pressures, myocardial reserve and pulmonary pressures that are not evident at rest. Until now, stress echocardiography requires validation in large cohorts to assess its prognostic power. This review highlights the importance of timely recognition of DBCM, underscores the advantages and disadvantages of current echocardiographic approaches and outlines future perspectives in multimodality imaging to improve patient outcomes.

Background/Objectives: Diabetic cardiomyopathy (DBCM) is characterized by cardiac dysfunction in the absence of ischemic heart disease, hypertension, or valvular disease, often manifesting as heart failure with preserved ejection fraction (HFpEF). Early recognition of DBCM is clinically important, as it enables timely initiation of tailored therapies and may slow down the progression to overt heart failure with reduced ejection fraction (HFrEF). This study aimed to evaluate the diagnostic utility of advanced echocardiographic techniques—myocardial work (MW), diastolic stress echocardiography (DSTE), Cardio-Ankle Vascular Index (CAVI)—and selected serum biomarkers in identifying DBCM. Methods: In this prospective observational study with 12-month follow-up, 125 diabetic patients with preserved ejection fraction and symptoms of HF or recent HF hospitalization were enrolled. Using the Heart Failure Association Pre-test Probability of HFpEF criteria, 37 were classified as DBCM-HFpEF and 88 as diabetic controls. An additional 47 age- and sex-matched non-diabetic individuals served as controls. All participants underwent resting echocardiography (MW, GLS), DSTE, CAVI assessment, and biomarker measurement (BNP, troponin, galectin-3). Results: Compared to non-diabetics, diabetic patients had significantly higher TRVmax (2.21 vs. 2.05 m/s), LAVI (39.70 vs. 33.50 mL/m²), E/e′ (8.64 vs. 7.59), CAVI (8.51 vs. 7.82 m/s), BNP (91.50 vs. 35.10 pg/mL), and troponin (3.94 vs. 2.43 ng/mL) (all p < 0.01), while galectin-3 levels showed no significant difference between groups. Differences were more pronounced between DBCM and No-DBCM diabetic groups. Multivariate analysis identified BNP (OR 5.45), TRVmax (OR 8.56), and CAVI (OR 1.91) as independent predictors of DBCM. Conclusions: DSTE and CAVI, alongside BNP and echocardiographic parameters, may provide valuable noninvasive tools for the early detection of DBCM in diabetic patients presenting with otherwise unexplained dyspnea, potentially enabling earlier intervention and improved outcomes. This is clinically important guiding an efficient management of an increasing number of diabetic patients presented with unexplained dyspnea.