The risk for development of cardiac stiffness/diastolic dysfunction is also high in those with type 2 diabetes. For example, observations from the Framingham Heart Study indicated that persons with type 2 diabetes had a two- to eight fold increased risk for development of heart failure and that 19% developed symptoms of heart failure. The pathophysiological processes behind DCM remain incompletely understood. There are several hypothesized mechanisms for the multifactorial occurrence of DCM, such as insulin resistance, microvascular impairment, abnormalities in subcellular components, metabolic disturbances, cardiac autonomic dysfunction, changes in the renin-angiotensin-aldosterone system (RAAS), and maladaptive immune response. The majority of the left ventricular filling (about 90%) in a healthy, normal heart happens passively before the next contraction of the left atrium. In healthy individuals, the left atrial contraction accounts for approximately 10% of the ventricular filling phase(active filling phase)..