1
|
Gözüküçük D, İleri BA, Başkan SK, Öztarhan E, Güller D, Önal H, Öztarhan K. Evaluation of cardiac autonomic dysfunctions in children with type 1 diabetes mellitus. BMC Pediatr 2024; 24:229. [PMID: 38561716 PMCID: PMC10986024 DOI: 10.1186/s12887-024-04644-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Cardiovascular autonomic neuropathy (CAN) is a serious complication of diabetes, impacting the autonomic nerves that regulate the heart and blood vessels. Timely recognition and treatment of CAN are crucial in averting the onset of cardiovascular complications. Both clinically apparent autonomic neuropathy and subclinical autonomic neuropathy, particularly CAN pose a significant risk of morbidity and mortality in children with type 1 diabetes mellitus (T1DM). Notably, CAN can progress silently before manifesting clinically. In our study, we assessed patients with poor metabolic control, without symptoms, following the ISPAD 2022 guideline. The objective is is to determine which parameters we can use to diagnose CAN in the subclinical period. METHODS Our study is a cross-sectional case-control study that includes 30 children diagnosed with T1DM exhibiting poor metabolic control (average HbA1c > 8.5% for at least 1 year) according to the ISPAD 2022 Consensus Guide. These patients, who are under the care of the pediatric diabetes clinic, underwent evaluation through four noninvasive autonomic tests: echocardiography, 24-h Holter ECG for heart rate variability (HRV), cardiopulmonary exercise test, and tilt table test. RESULTS The average age of the patients was 13.73 ± 1.96 years, the average diabetes duration was 8 ± 3.66 years, and the 1-year average HbA1c value was 11.34 ± 21%. In our asymptomatic and poorly metabolically controlled patient group, we found a decrease in HRV values, the presence of postural hypotension with the tilt table test, and a decrease in ventricular diastolic functions that are consistent with the presence of CAN. Despite CAN, the systolic functions of the ventricles were preserved, and the dimensions of the cardiac chambers and cardiopulmonary exercise test were normal. CONCLUSIONS CAN is a common complication of T1DM, often associated with the patient's age and poor glycemic control. HRV, active orthostatic tests, and the evaluation of diastolic dysfunctions play significant roles in the comprehensive assessment of CAN. These diagnostic measures are valuable tools in identifying autonomic dysfunction at an early stage, allowing for timely intervention and management to mitigate the impact of cardiovascular complications associated with T1DM.
Collapse
Affiliation(s)
- Davut Gözüküçük
- Department of Medicine, Division of Pediatrics, Sağlık Bilimleri University, Kanuni Sultan Süleyman Training and Research Hospital, Atakent Mh, Turgut Özal Bulvari No:46/1, Küçükçekmece, 34303, Istanbul, Turkey
| | - Berkut A İleri
- Department of Medicine, T.C. Demiroğlu Bilim University İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey
| | - Serra Karaca Başkan
- Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine Training and Research Hospital, Turgut Özal Millet St., Istanbul, Fatih, Topkapı, 34093, Turkey
| | - Ece Öztarhan
- Department of Medicine, Yeditepe University, Yeditepe Faculty of Medicine Training and Research Hospital, Koşuyolu, Koşuyolu Cd. No: 168, Kadıköy, 34718, Istanbul, Turkey
| | - Dilek Güller
- Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Gastroenterology, T.C. Demiroğlu Bilim University, İstanbul Florence Nightingale Hospital, İzzetpaşa Mah, Abide-I Hürriyet Cd No:166, Şişli, 34381, Istanbul, Turkey
| | - Hasan Önal
- Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Endocrinology and Metabolism, Sağlık Bilimleri University, Başakşehir Çam ve Sakura City Hosptial, Başakşehir Mahallesi G-434 Caddesi No: 2L, Başakşehir, Istanbul, Turkey
| | - Kazım Öztarhan
- Department of Medicine, Division of Pediatrics, Subdivision of Pediatric Cardiology, Istanbul University, Istanbul Faculty of Medicine Training and Research Hospital, Turgut Özal Millet St., Istanbul, Fatih, Topkapı, 34093, Turkey.
| |
Collapse
|
2
|
Reply to 'Blood pressure regulation is multifactorial in mitochondrial disorders'. J Hypertens 2022; 40:2082. [PMID: 36052530 DOI: 10.1097/hjh.0000000000003203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
3
|
Sperna Weiland NH, Hermanides J, van der Ster BJP, Hollmann MW, Preckel B, Stok WJ, van Lieshout JJ, Immink RV. Sevoflurane based anaesthesia does not affect already impaired cerebral autoregulation in patients with type 2 diabetes mellitus. Br J Anaesth 2018; 121:1298-1307. [PMID: 30442257 DOI: 10.1016/j.bja.2018.07.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/11/2018] [Accepted: 07/09/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The baroreflex regulates arterial blood pressure (BP). During periods when blood pressure changes, cerebral blood flow (CBF) is kept constant by cerebral autoregulation (CA). In patients with diabetes mellitus (DM), low baroreflex sensitivity (BRS) is associated with impaired CA. As sevoflurane-based anaesthesia obliterates BRS, we hypothesised that this could aggravate the already impaired CA in patients with DM resulting in a 'double-hit' on cerebral perfusion leading to increased fluctuations in blood pressure and cerebral perfusion. METHODS On the day before surgery, we measured CBF velocity (CBFV), heart rate, and BP to determine BRS and CA efficacy (CBFVmean-to-BPmean-phase lead) in 25 patients with DM and in 14 controls. During the operation, BRS and CA efficacy were determined during sevoflurane-based anaesthesia. Patients with DM were divided into a group with high BRS (DMBRS↑) and a group with low BRS (DMBRS↓). Values presented are median (inter-quartile range). RESULTS Preoperative vs intraoperative BRS was 6.2 (4.5-8.5) vs 1.9 (1.1-2.5, P<0.001) ms mm Hg-1 for controls, 5.8 (4.9-7.6) vs 2.7 (1.5-3.9, P<0.001) ms mm Hg-1 for patients with DMBRS↑, and 1.9 (1.5-2.8) vs 1.1 (0.6-2.5, P=0.31) ms mm Hg-1 for patients with DMBRS↓. Preoperative vs intraoperative CA efficacy was 43° (38-46) vs 43° (38-51, P=0.30), 44° (36-49) vs 41° (32-49, P=0.52), and 34° (28-40) vs 30° (27-38, P=0.64) for controls, DMBRS↑, and DMBRS↓ patients, respectively. CONCLUSIONS In diabetic patients with low preoperative BRS, preoperative CA efficacy was also impaired. In controls and diabetic patients, CA was unaffected by sevoflurane-based anaesthesia. We therefore conclude that sevoflurane-based anaesthesia does not contribute to a 'double-hit' phenomenon on cerebral perfusion. CLINICAL TRIAL REGISTRATION NCT 03071432.
Collapse
Affiliation(s)
- N H Sperna Weiland
- Amsterdam UMC, University of Amsterdam, Anaesthesiology, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Laboratory for Clinical Cardiovascular Physiology, Department of Medical Biology, Amsterdam, The Netherlands
| | - J Hermanides
- Amsterdam UMC, University of Amsterdam, Anaesthesiology, Amsterdam, The Netherlands.
| | - B J P van der Ster
- Amsterdam UMC, University of Amsterdam, Laboratory for Clinical Cardiovascular Physiology, Department of Medical Biology, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands
| | - M W Hollmann
- Amsterdam UMC, University of Amsterdam, Anaesthesiology, Amsterdam, The Netherlands
| | - B Preckel
- Amsterdam UMC, University of Amsterdam, Anaesthesiology, Amsterdam, The Netherlands
| | - W J Stok
- Amsterdam UMC, University of Amsterdam, Laboratory for Clinical Cardiovascular Physiology, Department of Medical Biology, Amsterdam, The Netherlands
| | - J J van Lieshout
- Amsterdam UMC, University of Amsterdam, Laboratory for Clinical Cardiovascular Physiology, Department of Medical Biology, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Internal Medicine, Amsterdam, The Netherlands; MRC/Arthritis Research UK Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham Medical School, Queen's Medical Centre, Nottingham, UK
| | - R V Immink
- Amsterdam UMC, University of Amsterdam, Anaesthesiology, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Laboratory for Clinical Cardiovascular Physiology, Department of Medical Biology, Amsterdam, The Netherlands
| |
Collapse
|
4
|
Cichosz SL, Frystyk J, Tarnow L, Fleischer J. Are Changes in Heart Rate Variability During Hypoglycemia Confounded by the Presence of Cardiovascular Autonomic Neuropathy in Patients with Diabetes? Diabetes Technol Ther 2017; 19:91-95. [PMID: 28118049 DOI: 10.1089/dia.2016.0342] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND We have recently shown how the combination of information from continuous glucose monitor (CGM) and heart rate variability (HRV) measurements can be used to construct an algorithm for prediction of hypoglycemia in both bedbound and active patients with type 1 diabetes (T1D). Questions remain on how cardiovascular autonomic neuropathy (CAN) influences these measurable changes. This study aims to examine if changes in HRV during hypoglycemia are confounded by the presence of CAN. METHODS Twenty-one adults (hereof 13 men) with T1D prone to hypoglycemia were recruited and monitored with CGM and a Holter device while they performed normal daily activities. CAN was diagnosed using two cardiac reflex tests: (1) deep breathing and (2) orthostatic hypotension and end organ symptoms. Early CAN was defined as the presence of one abnormal reflex test and severe CAN was defined as two abnormal tests or one abnormal test combined with symptoms of autonomic neuropathy. RESULTS A total of 19 hypoglycemic and corresponding euglycemia periods were identified among the 21 patients. Eleven patients were diagnosed with CAN, hereof five with severe CAN. The HRV parameter low frequency (LF) was significantly (P = 0.029) reduced during hypoglycemia. Changes in LF during hypoglycemia were not different between patients with and without CAN, -0.64 versus -0.48 log(LF) (P = 0.74). CONCLUSIONS Our data show that there are measurable changes in HRV during hypoglycemia, and present in both patients with and without CAN.
Collapse
Affiliation(s)
- Simon Lebech Cichosz
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
- 2 Department of Health Science and Technology, Aalborg University , Aalborg, Denmark
| | - Jan Frystyk
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
| | - Lise Tarnow
- 3 Steno Diabetes Center, Department of Clinical Epidemiology, Aarhus University and Nordsjaellands Hospitaler Hilleroed , Hillerød, Denmark
| | - Jesper Fleischer
- 1 Department of Endocrinology and Internal Medicine, Aarhus University Hospital and Medical Research Laboratory, Institute of Clinical Research, Aarhus University , Aarhus, Denmark
| |
Collapse
|
5
|
Abstract
Cardiac autonomic neuropathy (CAN) represents a serious complication as it carries an approximately five-fold risk of mortality in patients with diabetes just as in those with chronic liver diseases. The high mortality rate may be related to silent myocardial infarction, cardiac arrhythmias, cardiovascular and cardiorespiratory instability and to other causes not yet explained. Resting tachycardia due to parasympathetic damage may represent one of the earliest signs. Typical findings referring to autonomic dysfunction may include exercise intolerance, orthostatic hypotension and cardiac dysfunction to rest or exercise. Severe autonomic neuropathy may be responsible for spontaneous respiratory arrest and unexplained sudden death. A relationship between the presence and/or severity of CAN and corrected QT interval prolongation is well documented. Better understanding of the prognostic importance of autonomic neuropathy followed the use of simple non-invasive cardiovascular reflex tests. These most commonly include heart rate variation in response to deep breathing, standing, the Valsalva maneouvre and blood pressure response to standing and sustained handgrip. Near normoglycaemia is now generally accepted as the primary approach to the prevention of diabetic neuropathy, but is not achievable in most patients. Our experience of the use of the antioxidant alpha-lipoic acid in the treatment of cardiac autonomic neuropathy is described.
Collapse
Affiliation(s)
- Peter Kempler
- Department of Medicine, Semmelweis University, 1083 Budapest, Korányi S.u. 2/a, Hungary,
| |
Collapse
|
6
|
Refaie W. Assessment of cardiac autonomic neuropathy in long standing type 2 diabetic women. Egypt Heart J 2014. [DOI: 10.1016/j.ehj.2013.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
|
7
|
Neuropatía autonómica diabética cardiovascular. REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70031-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
8
|
Karayannis G, Giamouzis G, Cokkinos DV, Skoularigis J, Triposkiadis F. Diabetic cardiovascular autonomic neuropathy: clinical implications. Expert Rev Cardiovasc Ther 2013; 10:747-65. [PMID: 22894631 DOI: 10.1586/erc.12.53] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic cardiovascular autonomic neuropathy (DCAN), the impairment of the autonomic balance of the cardiovascular system in the setting of diabetes mellitus (DM), is frequently observed in both Type 1 and 2 DM, has detrimental effects on the quality of life and portends increased mortality. Clinical manifestations include: resting heart rate disorders, exercise intolerance, intraoperative cardiovascular lability, orthostatic alterations in heart rate and blood pressure, QT-interval prolongation, abnormal diurnal and nocturnal blood pressure variation, silent myocardial ischemia and diabetic cardiomyopathy. Clinical tests for autonomic nervous system evaluation, heart rate variability analysis, autonomic innervation imaging techniques, microneurography and baroreflex analysis are the main diagnostic tools for DCAN detection. Aldose reductase inhibitors and antioxidants may be helpful in DCAN therapy, but a regular, more generalized and multifactorial approach should be adopted with inclusion of lifestyle modifications, strict glycemic control and treatment of concomitant traditional cardiovascular risk factors, in order to achieve the best therapeutic results. In the present review, the authors provide aspects of DCAN pathophysiology, clinical presentation, diagnosis and an algorithm regarding the evaluation and management of DCAN in DM patients.
Collapse
|
9
|
Spallone V, Ziegler D, Freeman R, Bernardi L, Frontoni S, Pop-Busui R, Stevens M, Kempler P, Hilsted J, Tesfaye S, Low P, Valensi P. Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev 2011; 27:639-53. [PMID: 21695768 DOI: 10.1002/dmrr.1239] [Citation(s) in RCA: 545] [Impact Index Per Article: 41.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 05/10/2011] [Indexed: 12/14/2022]
Abstract
The Cardiovascular Autonomic Neuropathy (CAN) Subcommittee of the Toronto Consensus Panel on Diabetic Neuropathy worked to update CAN guidelines, with regard to epidemiology, clinical impact, diagnosis, usefulness of CAN testing, and management. CAN is the impairment of cardiovascular autonomic control in the setting of diabetes after exclusion of other causes. The prevalence of confirmed CAN is around 20%, and increases up to 65% with age and diabetes duration. Established risk factors for CAN are glycaemic control in type 1 and a combination of hypertension, dyslipidaemia, obesity, and glycaemic control in type 2 diabetes. CAN is a risk marker of mortality and cardiovascular morbidity, and possibly a progression promoter of diabetic nephropathy. Criteria for CAN diagnosis and staging are: (1) one abnormal cardiovagal test result identifies possible or early CAN; (2) at least two abnormal cardiovagal test results are required for definite or confirmed CAN; and (3) the presence of orthostatic hypotension in addition to abnormal heart rate test results identifies severe or advanced CAN. Progressive stages of CAN are associated with increasingly worse prognosis. CAN assessment is relevant in clinical practice for (1) diagnosis of CAN clinical forms, (2) detection and tailored treatment of CAN clinical correlates (e.g. tachycardia, orthostatic hypotension, non-dipping, QT interval prolongation), (3) risk stratification for diabetic complications and cardiovascular morbidity and mortality, and (4) modulation of targets of diabetes therapy. Evidence on the cost-effectiveness of CAN testing is lacking. Apart from the preventive role of intensive glycaemic control in type 1 diabetes, recommendations cannot be made for most therapeutic approaches to CAN.
Collapse
Affiliation(s)
- Vincenza Spallone
- Department of Internal Medicine, University of Tor Vergata, Rome, Italy.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
The ECG vertigo in diabetes and cardiac autonomic neuropathy. EXPERIMENTAL DIABETES RESEARCH 2011; 2011:687624. [PMID: 21747831 PMCID: PMC3124253 DOI: 10.1155/2011/687624] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2010] [Accepted: 03/02/2011] [Indexed: 01/20/2023]
Abstract
The importance of diabetes in the epidemiology of cardiovascular diseases cannot be overemphasized. About one third of acute myocardial infarction patients have diabetes, and its prevalence is steadily increasing. The decrease in cardiac mortality in people with diabetes is lagging behind that of the general population. Cardiovascular disease is a broad term which includes any condition causing pathological changes in blood vessels, cardiac muscle or valves, and cardiac rhythm. The ECG offers a quick, noninvasive clinical and research screen for the early detection of cardiovascular disease in diabetes. In this paper, the clinical and research value of the ECG is readdressed in diabetes and in the presence of cardiac autonomic neuropathy.
Collapse
|
11
|
Moore DJ, Gregory JM, Kumah-Crystal YA, Simmons JH. Mitigating micro-and macro-vascular complications of diabetes beginning in adolescence. Vasc Health Risk Manag 2009; 5:1015-31. [PMID: 19997571 PMCID: PMC2788594 DOI: 10.2147/vhrm.s4891] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Indexed: 01/26/2023] Open
Abstract
Diabetes is a chronic disorder, which manifests when insulin levels or resistance to insulin action becomes insufficient to control systemic glucose levels. Although the number of available agents to manage diabetes continues to expand rapidly, the maintenance of euglycemia by individuals with diabetes remains a substantial challenge. Unfortunately, many patients with type 1 and type 2 diabetes will ultimately experience diabetes complications. These complications result from the toxic effects of chronic hyperglycemia combined with other metabolic derangements that afflict persons with diabetes. This review will present a comprehensive look at the complications of diabetes, the risk factors for their progression, the mechanistic basis for their development, and the clinical approach to screening for, preventing, and treating these sequelae. In addition, since diabetes is commonly diagnosed in childhood, we will provide a special focus on the care of the adolescent patient.
Collapse
Affiliation(s)
- Daniel J Moore
- Department of Pediatrics, Division of Endocrinology and Diabetes, Vanderbilt Children's Hospital, Nashville, TN 37232-9170, USA
| | | | | | | |
Collapse
|
12
|
Spallone V, Morganti R, Fedele T, D'Amato C, Maiello MR. Reappraisal of the diagnostic role of orthostatic hypotension in diabetes. Clin Auton Res 2009; 19:58-64. [PMID: 19199088 DOI: 10.1007/s10286-009-0517-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2008] [Accepted: 01/05/2009] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Given the controversial aspects of orthostatic hypotension (OH) testing in diabetes, we evaluated the diagnostic role for cardiac autonomic neuropathy (CAN) and for nondipping of OH, defined according to a fall in systolic blood pressure (BP) > or = 30 (30-OH) or > or = 20 mmHg (20-OH). METHODS 164 diabetic patients underwent 24 hours BP monitoring, three heart rate cardiovascular tests, and OH test. RESULTS Compared to 30 mmHg, the 20 mmHg criterion increased the frequency of OH from 11 to 19.5%. Both 30-OH and 20-OH were associated with CAN (chi (2) = 30.5, P < 0.0001, and chi (2) = 45.1, P < 0.0001, respectively) and nondipping (chi (2) = 31.7, P < 0.0001, and chi (2) = 17.2, P = 0.0001, respectively). ROC curve for orthostatic systolic BP fall provided an AUC of 0.79 +/- 0.04 (95% CI 0.70-0.86) for diagnosing CAN and of 0.77 +/- 0.05 (95% CI 0.66-0.86) for diagnosing nondipping. Both 30-OH and 20-OH showed a low sensitivity and high specificity for CAN [sensitivity 31%, specificity 98%, Likelihood Ratio for a positive result (LR(+)) 17.1; and sensitivity 50%, specificity 95%, LR(+) 9.3, respectively], and for nondipping (sensitivity 40%, specificity 96%, LR(+) 8.9, and sensitivity 47%, specificity 87%, LR(+) 3.5, respectively), having 30-OH a higher LR(+) in both cases. INTERPRETATION OH had only moderate diagnostic accuracy, with high specificity and low sensitivity, for CAN, diagnosed on the basis of heart rate cardiovascular tests, and-as a novel finding-also for nondipping. A different definition of OH did not substantially affect its diagnostic characteristics, with just a slightly greater ability of the 30 mmHg criterion to estimate the probability of CAN and nondipping.
Collapse
Affiliation(s)
- Vincenza Spallone
- Endocrinology, Dept. of Internal Medicine, University of Tor Vergata, Via Montpellier 81, Rome, Italy.
| | | | | | | | | |
Collapse
|
13
|
Wu JS, Yang YC, Lu FH, Wu CH, Wang RH, Chang CJ. Population-based study on the prevalence and risk factors of orthostatic hypotension in subjects with pre-diabetes and diabetes. Diabetes Care 2009; 32:69-74. [PMID: 18852335 PMCID: PMC2606833 DOI: 10.2337/dc08-1389] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the relationship between pre-diabetes and orthostatic hypotension and to examine the prevalence and correlates of orthostatic hypotension in community dwellers with normal glucose tolerance (NGT), pre-diabetes, and diabetes. RESEARCH DESIGN AND METHODS All participants were classified as having NGT (n = 1,069), pre-diabetes (n = 412), or diabetes (n = 157). Orthostatic hypotension was defined as a decline in systolic/diastolic blood pressure of > or =20/10 mmHg when an individual changed from a supine to a standing position. The cardiovagal response to standing was the ratio between the longest RR interval around beat 30 and the shortest RR interval around beat 15 after standing (30 max-to-15 min ratio). RESULTS The prevalences of orthostatic hypotension were 13.8, 17.7, and 25.5% in subjects with NGT, pre-diabetes, and diabetes, respectively. For all subjects, age, diabetes, hypertension, and a decreased 30 max-to-15 min ratio, but not pre-diabetes, were independently associated with orthostatic hypotension. Age, hypertension, and 30 max-to-15 min ratio were the correlates of orthostatic hypotension in NGT subjects. Age and hypertension were related to orthostatic hypotension in pre-diabetic subjects. A1C and hypertension were the determinants of orthostatic hypotension in diabetic subjects. Supine blood pressure was related to orthostatic hypotension in all subjects and subgroups. CONCLUSIONS Pre-diabetic subjects do not have a higher risk of orthostatic hypotension than subjects with NGT, although the risk of orthostatic hypotension is higher in diabetic subjects. Hypertension and supine blood pressure were risk factors for orthostatic hypotension in both pre-diabetic and diabetic subjects. Age and A1C were the correlates of orthostatic hypotension in pre-diabetic and diabetic subjects, respectively. The cardiovagal response to standing is an important determinant of orthostatic hypotension in subjects with NGT but not in pre-diabetic and diabetic subjects.
Collapse
Affiliation(s)
- Jin-Shang Wu
- Department of Family Medicine, College of Medicine, National Cheng Kung University, Taiwan, Republic of China
| | | | | | | | | | | |
Collapse
|
14
|
Chen HT, Lin HD, Won JGS, Lee CH, Wu SC, Lin JD, Juan LY, Ho LT, Tang KT. Cardiovascular autonomic neuropathy, autonomic symptoms and diabetic complications in 674 type 2 diabetes. Diabetes Res Clin Pract 2008; 82:282-90. [PMID: 18824270 DOI: 10.1016/j.diabres.2008.08.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Revised: 08/11/2008] [Accepted: 08/15/2008] [Indexed: 12/19/2022]
Abstract
AIMS To determine the relationships between cardiovascular autonomic neuropathy (CAN) and autonomic symptoms, clinical parameters and diabetic complications in type 2 diabetes (T2DM). METHODS The results of autonomic symptoms, clinical parameters, diabetes complications and cardiovascular reflex (CVR) tests of 674 T2DM were analyzed. RESULTS Significant correlations were found between CAN risk and age (p=0.019), duration of diabetes (p=0.008), HbA1c (p<0.001), systolic blood pressure (p=0.006), nephropathy (p<0.001), retinopathy (p<0.001), and QTc interval (p<0.001), but not BMI and hyperlipidemia. Patients with retinopathy or proteinuria had increase risk of CAN, and proliferative diabetic retinopathy (PDR) was the most significant risk factor (odds ratio: 6.85; 95% CI: 2.32-20.20) for CAN. Eighty-three percent of patients complained of autonomic symptoms; and the more symptoms complained, the higher the prevalence of CAN. Impotence was the only single symptom associated with CAN risk. Additional CAN risks were also observed when patients with multiple symptoms and/or complications in combinations. CONCLUSIONS Our results implied that patients with multiple symptoms and/or complications in combinations have increased CAN risk, and this may provide additional information for clinicians to identify T2DM at risk of having CAN.
Collapse
Affiliation(s)
- Hung-Ta Chen
- Division of Endocrinology and Metabolism, Yangming Branch, Taipei City Hospital, Taipei, Taiwan
| | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Quattrini C, Jeziorska M, Tavakoli M, Begum P, Boulton AJM, Malik RA. The Neuropad test: a visual indicator test for human diabetic neuropathy. Diabetologia 2008; 51:1046-50. [PMID: 18368386 DOI: 10.1007/s00125-008-0987-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2007] [Accepted: 02/22/2008] [Indexed: 10/22/2022]
Abstract
AIMS/HYPOTHESIS The commercially available Neuropad test was developed as a simple visual indicator test to evaluate diabetic neuropathy. It uses a colour change to define the integrity of skin sympathetic cholinergic innervation. We compared the results of Neuropad assessment in the foot with established measures of somatic and autonomic neuropathy. METHODS Fifty-seven diabetic patients underwent Neuropad assessment, quantitative sensory and autonomic function testing, and evaluation of intra-epidermal nerve fibre density in foot skin biopsies. RESULTS Neuropad responses correlated with the neuropathy disability score (r(s)=0.450, p<0.001), neuropathic symptom score (r(s)=0.288, p=0.03), cold detection threshold (r(s)=0.394, p = 0.003), heat-as-pain perception threshold visual analogue score 0.5 (r(s)=0.279, p=0.043) and deep-breathing heart rate variability (r(s)= -0.525, p<0.001). Intra-epidermal nerve fibre density (fibres/mm) compared with age- and sex-matched control subjects (11.06+/-0.82) was non-significantly reduced (7.37+/-0.93) in diabetic patients with a normal Neuropad response and significantly reduced in patients with a patchy (5.01+/-0.93) or absent (5.02+/-0.77) response (p=0.02). The sensitivity of an abnormal Neuropad response in detecting clinical neuropathy (neuropathy disability score >or=5) was 85% (negative predictive value 71%) and the specificity was 45% (positive predictive value 69%). CONCLUSIONS/INTERPRETATION The Neuropad test may be a simple indicator for screening patients with diabetic neuropathy.
Collapse
Affiliation(s)
- C Quattrini
- Division of Cardiovascular Medicine, Core Technology Facility, University of Manchester, 46 Grafton Street, Manchester M13 9NT, UK
| | | | | | | | | | | |
Collapse
|
16
|
Istenes I, Keresztes K, Tündik A, Hermányi Z, Putz Z, Vargha P, Kertész T, Emery C, Gandhi R, Tesfaye S, Kempler P. Blood pressure response to standing in the diagnosis of autonomic neuropathy: are initial (supine) values of importance. Diabet Med 2007; 24:325-7. [PMID: 17305794 DOI: 10.1111/j.1464-5491.2007.02088.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
17
|
Complicaciones crónicas, factores de riesgo cardiovascular y HbA1c en la diabetes mellitus tipo 1 a los 14 años de diagnóstico. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1575-0922(05)71048-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
18
|
Nemes A, Lengyel C, Forster T, Várkonyi TT, Takács R, Nagy I, Kempler P, Lonovics J, Csanády M. Coronary flow reserve, insulin resistance and blood pressure response to standing in patients with normoglycaemia: is there a relationship? Diabet Med 2005; 22:1614-8. [PMID: 16241931 DOI: 10.1111/j.1464-5491.2005.01681.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIMS To establish the relationships between coronary flow reserve, cardiovascular autonomic function, and insulin resistance characterized by the homeostasis model assessment insulin resistance score in patients with normal carbohydrate metabolism according to the World Health Organization (WHO) and American Diabetes Association (ADA) criteria, and with morphologically normal epicardial coronary arteries. METHODS Twenty-five patients [12 women and 13 men, mean (sd) age: 53 +/- 11 years] with normal coronary angiography were enrolled into the study. Coronary flow reserve was measured during stress transoesophageal echocardiography. Autonomic dysfunction was assessed by means of five standard cardiovascular reflex tests. The fasting serum glucose and insulin levels were determined and the homeostasis assessment model insulin resistance score was calculated. RESULTS In patients with normal carbohydrate metabolism, negative correlations were observed between the coronary flow reserve and both the serum insulin level (r = -0.445, P = 0.026) and the homeostasis assessment model insulin resistance score (r = -0.449, P = 0.024). The systolic blood pressure response to standing also correlated with the coronary flow reserve (r = -0.519, P = 0.011). The heart rate response to deep breathing, the Valsalva ratio, the 30/15 ratio and the sustained handgrip test results were not correlated with the coronary flow reserve. CONCLUSIONS Our data suggest the possible role of insulin resistance and early sympathetic nerve dysfunction in the development of decreased coronary flow reserve in patients without diabetes mellitus or impaired glucose tolerance.
Collapse
Affiliation(s)
- A Nemes
- First Department of Medicine, Medical Faculty, Albert Szent-Györgyi Medical and Pharmaceutical Centre, University of Szeged, Korányi fasor 10, H-6720 Szeged, Hungary
| | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Witte DR, Tesfaye S, Chaturvedi N, Eaton SEM, Kempler P, Fuller JH. Risk factors for cardiac autonomic neuropathy in type 1 diabetes mellitus. Diabetologia 2005; 48:164-71. [PMID: 15619072 DOI: 10.1007/s00125-004-1617-y] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2004] [Accepted: 09/23/2004] [Indexed: 12/16/2022]
Abstract
AIMS/HYPOTHESIS Cardiac autonomic neuropathy (CAN) is associated with increased morbidity and mortality in type 1 diabetes. Apart from glycaemic control, risk factors for CAN have not been extensively studied. METHODS As part of the EURODIAB Prospective Complications Study, CAN--defined as either a loss of heart rate variability or postural hypotension on standing--was assessed at baseline and follow-up (7.3+/-0.6 years from baseline) in patients with type 1 diabetes. RESULTS Follow-up measurements were available for 956 participants without CAN at baseline (age at baseline 31.3+/-8.9 years, duration of diabetes 13.5+/-8.3 years). During follow-up, 163 (17%) subjects developed CAN, yielding an incidence of 23.4 per 1,000 person-years. Blood pressure, weight, the presence of cardiovascular disease, albuminuria, distal symmetrical polyneuropathy (DSP) and retinopathy at baseline were associated with the incidence of CAN after adjustment for sex, duration of diabetes and HbA(1)c. In a multivariate regression model, baseline factors associated with an increased risk of developing CAN were age [odds ratio (OR)=1.3 per decade, 95% CI 1.1-1.7], HbA(1)c (OR=1.2 per percentage point, 95% CI 1.1-1.4), systolic blood pressure (OR=1.1 per 10 mmHg, 95% CI 1.0-1.3), feeling faint on standing (OR=2.0, 95% CI 1.2-3.2), DSP (OR=1.9, 95% CI 1.2-3.0) and retinopathy (OR=1.7, 95% CI 1.1-2.6). CONCLUSION/INTERPRETATION This study confirms the importance of exposure to hyperglycaemia as a risk factor for CAN. A small set of variables, including HbA(1)c, hypertension, DSP and retinopathy, predict the risk of CAN. Clinical trials are needed to address the impact of intensive antihypertensive treatment on CAN in type 1 diabetes.
Collapse
Affiliation(s)
- D R Witte
- Department of Epidemiology and Public Health, Royal Free and University College London Medical School, 1-19 Torrington Place, London, WC1E 6BT, UK.
| | | | | | | | | | | |
Collapse
|