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Eleftheriadou A, Spallone V, Tahrani AA, Alam U. Cardiovascular autonomic neuropathy in diabetes: an update with a focus on management. Diabetologia 2024:10.1007/s00125-024-06242-0. [PMID: 39120767 DOI: 10.1007/s00125-024-06242-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/10/2024] [Indexed: 08/10/2024]
Abstract
Cardiovascular autonomic neuropathy (CAN) is an under-recognised yet highly prevalent microvascular complication of diabetes. CAN affects approximately 20% of people with diabetes, with recent studies highlighting the presence of CAN in prediabetes (impaired glucose tolerance and/or impaired fasting glucose), indicating early involvement of the autonomic nervous system. Understanding of the pathophysiology of CAN continues to evolve, with emerging evidence supporting a potential link between lipid metabolites, mitochondrial dysfunction and genetics. Recent advancements, such as streamlining CAN detection through wearable devices and monitoring of heart rate variability, present simplified and cost-effective approaches for early CAN detection. Further research on the optimal use of the extensive data provided by such devices is required. Despite the lack of specific pharmacological interventions targeting the underlying pathophysiology of autonomic neuropathy, several studies have suggested a favourable impact of newer glucose-lowering agents, such as sodium-glucose cotransporter 2 inhibitors and glucagon-like peptide-1 receptor agonists, where there is a wealth of clinical trial data on the prevention of cardiovascular events. This review delves into recent developments in the area of CAN, with emphasis on practical guidance to recognise and manage this underdiagnosed condition, which significantly increases the risk of cardiovascular events and mortality in diabetes.
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Affiliation(s)
- Aikaterini Eleftheriadou
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Abd A Tahrani
- Institute of Metabolism and Systems, School of Clinical and Experimental Medicine, University of Birmingham, Birmingham, UK
- Department of Diabetes and Endocrinology, Birmingham Heartlands Hospital, Birmingham, UK
| | - Uazman Alam
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Department of Medicine, University Hospital Aintree, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK.
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Anh Hoang T, Tran NL, Nguyen NT, Huyen Hoang LT, Vo NTM, Nguyen VX. Prognosis value of heart rate variability measured by Camera HRV application in patients after acute myocardial infarction. Indian Heart J 2024:S0019-4832(24)00156-1. [PMID: 39029797 DOI: 10.1016/j.ihj.2024.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Revised: 06/17/2024] [Accepted: 07/12/2024] [Indexed: 07/21/2024] Open
Abstract
A prospective cohort study was conducted to assess the prognostic significance of heart rate variability (HRV) measured by the HRV Camera application in predicting major adverse cardiovascular events (MACE) and all-cause mortality within 3 months after percutaneous coronary intervention (PCI). Of 101 patients, 25 developed MACE and 6 died. Low HRV (SDNN and rMSSD) is associated with increased MACE (p < 0.001 and p = 0.014, respectively) and all-cause mortality rates (p = 0.025 and p = 0.032, respectively). Our study concludes that HRV measured by smartphone applications has significant potential as predictive indicators of MACE and all-cause mortality after PCI, particularly SDNN.
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Affiliation(s)
- Tien Anh Hoang
- Cardiology Department of Hue University of Medicine and Pharmacy Hospital, Hue City, Thua Thien Hue, Viet Nam; Department of Internal Medicine, University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam.
| | - Nhat Long Tran
- University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam
| | - Nguyen Trung Nguyen
- University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam
| | - Linh Thi Huyen Hoang
- University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam
| | - Ngoc Thi Minh Vo
- University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam
| | - Vu Xuan Nguyen
- University of Medicine and Pharmacy, Hue University, Hue City, Thua Thien Hue, Viet Nam
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Irlik K, Aldosari H, Hendel M, Kwiendacz H, Piaśnik J, Kulpa J, Ignacy P, Boczek S, Herba M, Kegler K, Coenen F, Gumprecht J, Zheng Y, Lip GYH, Alam U, Nabrdalik K. Artificial intelligence-enhanced electrocardiogram analysis for identifying cardiac autonomic neuropathy in patients with diabetes. Diabetes Obes Metab 2024; 26:2624-2633. [PMID: 38603589 DOI: 10.1111/dom.15578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 03/12/2024] [Accepted: 03/15/2024] [Indexed: 04/13/2024]
Abstract
AIM To develop and employ machine learning (ML) algorithms to analyse electrocardiograms (ECGs) for the diagnosis of cardiac autonomic neuropathy (CAN). MATERIALS AND METHODS We used motif and discord extraction techniques, alongside long short-term memory networks, to analyse 12-lead, 10-s ECG tracings to detect CAN in patients with diabetes. The performance of these methods with the support vector machine classification model was evaluated using 10-fold cross validation with the following metrics: accuracy, precision, recall, F1 score, and area under the receiver-operating characteristic curve (AUC). RESULTS Among 205 patients (mean age 54 ± 17 years, 54% female), 100 were diagnosed with CAN, including 38 with definite or severe CAN (dsCAN) and 62 with early CAN (eCAN). The best model performance for dsCAN classification was achieved using both motifs and discords, with an accuracy of 0.92, an F1 score of 0.92, a recall at 0.94, a precision of 0.91, and an excellent AUC of 0.93 (95% confidence interval [CI] 0.91-0.94). For the detection of any stage of CAN, the approach combining motifs and discords yielded the best results, with an accuracy of 0.65, F1 score of 0.68, a recall of 0.75, a precision of 0.68, and an AUC of 0.68 (95% CI 0.54-0.81). CONCLUSION Our study highlights the potential of using ML techniques, particularly motifs and discords, to effectively detect dsCAN in patients with diabetes. This approach could be applied in large-scale screening of CAN, particularly to identify definite/severe CAN where cardiovascular risk factor modification may be initiated.
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Affiliation(s)
- Krzysztof Irlik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- Doctoral School, Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Hanadi Aldosari
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Computer Science, School of Electrical Engineering, Electronics and Computer Science, University of Liverpool, Liverpool, UK
| | - Mirela Hendel
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Hanna Kwiendacz
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Julia Piaśnik
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Justyna Kulpa
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Paweł Ignacy
- Doctoral School, Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Sylwia Boczek
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Mikołaj Herba
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Kamil Kegler
- Student's Scientific Association at the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Frans Coenen
- Department of Computer Science, School of Electrical Engineering, Electronics and Computer Science, University of Liverpool, Liverpool, UK
| | - Janusz Gumprecht
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Yalin Zheng
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Eye and Vision Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- St Paul's Eye Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Uazman Alam
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Diabetes & Endocrinology Research and Pain Research Institute, Institute of Life Course and Medical Sciences, University of Liverpool and Liverpool University Hospital NHS Foundation Trust, Liverpool, UK
- Centre for Biomechanics and Rehabilitation Technologies, Staffordshire University, Stoke-on-Trent, UK
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
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Tang Y, Ang L, Jaiswal M, Dillon BR, Esfandiari NH, Shah HS, Spino C, Plunkett C, Perkins BA, Pop-Busui R, Doria A. Cardiovascular Autonomic Neuropathy and Risk of Kidney Function Decline in Type 1 and Type 2 Diabetes: Findings From the PERL and ACCORD Cohorts. Diabetes 2024; 73:751-762. [PMID: 37467433 PMCID: PMC11043059 DOI: 10.2337/db23-0247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023]
Abstract
Results of previous studies have suggested that cardiovascular autonomic neuropathy (CAN) may predict rapid kidney function decline among people with diabetes. We analyzed the association between baseline CAN and subsequent glomerular filtration rate (GFR) decline among individuals with type 1 diabetes (T1D) from the Preventing Early Renal Loss in Diabetes (PERL) study (N = 469) and with type 2 diabetes (T2D) from Action to Control Cardiovascular Risk in Diabetes (ACCORD) (N = 7,973). Baseline CAN was ascertained with electrocardiogram-derived heart rate variability indices. Its association with GFR slopes, rapid kidney function decline (GFR loss of ≥5 mL/min/1.73 m2/year), and ≥40% GFR loss was evaluated by linear mixed-effects, logistic, and Cox regression, respectively. Participants with CAN experienced more rapid GFR decline, by an excess 1.15 mL/min/1.73 m2/year (95% CI -1.93 to -0.37; P = 4.0 × 10-3) in PERL and 0.34 mL/min/1.73 m2/year (95% CI -0.49 to -0.19; P = 6.3 × 10-6) in ACCORD. This translated to 2.11 (95% CI 1.23-3.63; P = 6.9 × 10-3) and 1.39 (95% CI 1.20-1.61; P = 1.1 × 10-5) odds ratios of rapid kidney function decline in PERL and ACCORD, respectively. Baseline CAN was also associated with a greater risk of ≥40% GFR loss events during follow-up (hazard ratio 2.60 [95% CI 1.15-5.45], P = 0.02, in PERL and hazard ratio 1.54 [95% CI 1.28-1.84], P = 3.8 × 10-6, in ACCORD). These associations remained significant after adjustment for potential confounders, including baseline GFR and albuminuria. Our findings indicate that CAN is a strong, independent predictor of rapid kidney function decline in both T1D and T2D. Further studies of the link between these two complications may help with development of new therapies to prevent kidney function decline in patients with diabetes. ARTICLE HIGHLIGHTS
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Affiliation(s)
- Yaling Tang
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Lynn Ang
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Mamta Jaiswal
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Brendan R. Dillon
- Department of Medicine, NYU Grossman School of Medicine, New York, NY
| | - Nazanene H. Esfandiari
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Hetal S. Shah
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
| | - Cathie Spino
- Statistical Analysis of Biomedical and Educational Research (SABER), University of Michigan, Ann Arbor, MI
| | - Cindy Plunkett
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Bruce A. Perkins
- Division of Endocrinology, University of Toronto, Toronto, Canada
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Alessandro Doria
- Research Division, Joslin Diabetes Center, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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Eren N, Onk D, Koç A, Kuyrukluyildiz U, Nalbant RA. The Effect of Intra-abdominal Pressure on Heart Rate Variability and Hemodynamics During Laparoscopic Cholecystectomy: A Prospective Observational Study. Cureus 2024; 16:e57890. [PMID: 38725775 PMCID: PMC11079955 DOI: 10.7759/cureus.57890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction This study aimed to evaluate hemodynamic changes using heart rate variability (HRV) measurements in diabetic and nondiabetic patients who will undergo laparoscopic cholecystectomy and to provide our preoperative measurements to guide us for better perioperative anesthesia management. Materials and methods The study included 143 patients aged 40 years and older who would undergo elective laparoscopic surgery, did not have any comorbidities other than diabetes mellitus (DM) type II, and were in the American Society of Anesthesiologists (ASA) class I-III risk group. Patients were divided into two groups: the control group (n = 77) and the DM group (n = 66). The preoperative glycated hemoglobin (HbA1C) level was measured. Peripheral oxygen saturation (SpO2) and hemodynamic parameters such as systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), and HRV parameters were measured preoperatively, perioperatively, and postoperatively. Intra-abdominal pressure (IAP) was administered at 10-12 mmHg. Results Even though SAP, DAP, MAP, and HR decreased with induction, they increased with insufflation, and an overall decrease was seen at the postoperative 24th hour for all parameters. When the groups were evaluated, no difference was observed except that the DAP was significantly lower in the DM group (p = 0.029) at insufflation and the HR was higher in the DM group at induction, and the difference was significant (p = 0.001). Preoperative HRV parameters were significantly lower in the DM group. According to the HRV parameters, although a decrease was observed after induction and insufflation, conversely, an increase was observed postoperatively. When the postoperative and preoperative values were compared, the standard deviation of the NN (R-R) intervals (SDNN), SDNN index, high frequency (HF), low frequency (LF), and LF/HF parameters were found to be significantly lower in the DM group than in the control group. Conclusion Diabetic patients are more sensitive to increased intra-abdominal pressure (IAP) in laparoscopic surgery, and the effects on cardiac autonomic functions can be determined by HRV measurements without clinically reflecting on hemodynamic data. Additionally, in diabetic patients with preoperative LF and/or HF values less than 100, we believe that careful follow-up in terms of autonomic neuropathy complications and anesthesia management should be done more meticulously in these patients.
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Affiliation(s)
- Nurhan Eren
- Department of Anesthesiology, Erzincan Binali Yıldırım University Mengucek Gazi Training and Research Hospital, Erzincan, TUR
| | - Didem Onk
- Department of Anesthesiology and Reanimation, Erzincan Binali Yıldırım University, Erzincan, TUR
| | - Alparslan Koç
- Department of Anesthesiology and Reanimation, Erzincan Binali Yıldırım University, Erzincan, TUR
| | - Ufuk Kuyrukluyildiz
- Department of Anesthesiology and Reanimation, Erzincan Binali Yıldırım University, Erzincan, TUR
| | - Remziye Ayşenur Nalbant
- Department of Anesthesiology and Reanimation, Erzincan Binali Yıldırım University, Erzincan, TUR
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Gupta P, Doherty L, Temprosa M, Pop-Busui R, Gadde KM, Singh P, Owora AH, Wessells H, Sarma AV. Prevalence and predictors of female sexual dysfunction among sexually active women in the diabetes prevention program outcomes study. Neurourol Urodyn 2024; 43:977-990. [PMID: 38501372 DOI: 10.1002/nau.25436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 01/30/2024] [Accepted: 02/19/2024] [Indexed: 03/20/2024]
Abstract
OBJECTIVE To determine the burden and identify correlates of female sexual dysfunction (FSD) among women with prediabetes (PreD) and type 2 diabetes (T2D) enrolled in the Diabetes Prevention Program (DPP) Outcomes Study (DPPOS). METHODS The DPPOS visit included the Female Sexual Function Index (FSFI) to determine sexual function. Of 1464 participants, 1320 (90%) completed the (FSFI) and 426 were sexually active. A backward selection multivariable logistic regression model estimated the odds of FSD for sociodemographic, clinical, and diabetes-related covariates. RESULTS One hundred and eighty-five (43%) had a score of ≤26.55 and met the criteria for FSD. After adjustment for DPP treatment and age, urinary incontinence (UI) (odds ratio [OR] = 1.91, 95% confidence interval [CI] = 1.15-3.17) and hysterectomy (OR = 1.89, 95% CI = 1.01-3.53) were associated with increased odds of FSD. Increased body mass index was protective for FSD (OR = 0.93 per kg/m2, 95% CI = 0.89-0.96). Michigan Neuropathy Screening Instrument-based peripheral neuropathy (mean±SD scores 1.1±1.3 vs. 0.9±1.1, p < 0.0001) and Electrocardiogram (ECG)-based autonomic dysfunction measures (mean ± SD heart rate levels 64.3 ± 6.8 vs. 65.6 ± 10.2, p = 0.008) were associated with FSD. There were no differences in diabetes rates between women who did (66.5%) and did not (66%) have (p = 0.7). CONCLUSIONS FSD is prevalent in women with PreD and T2D. Our findings suggest that FSD is associated with neuropathic complications commonly observed in PreD and T2D.
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Affiliation(s)
- Priyanka Gupta
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lindsay Doherty
- Department of Biostatistics and Bioinformatics, Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Marinella Temprosa
- Department of Biostatistics and Bioinformatics, Biostatistics Center, Milken Institute School of Public Health, George Washington University, Washington, District of Columbia, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kishore M Gadde
- Department of Surgery, University of California Irvine, Orange, California, USA
| | - Prachi Singh
- Pennington Biomedical Research Center, Louisiana State University System, Baton Rouge, Louisiana, USA
| | - Arthur H Owora
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, Indiana, USA
| | - Hunter Wessells
- Department of Urology and Diabetes, Research Center, University of Washington School of Medicine, Seattle, Washington, USA
| | - Aruna V Sarma
- Department of Urology, University of Michigan, Ann Arbor, Michigan, USA
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Davis TME, Tan E, Davis WA. Prevalence and prognostic significance of cardiac autonomic neuropathy in community-based people with type 2 diabetes: the Fremantle Diabetes Study Phase II. Cardiovasc Diabetol 2024; 23:102. [PMID: 38500197 PMCID: PMC10949593 DOI: 10.1186/s12933-024-02185-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 03/01/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND There is a paucity of contemporary data on the prevalence and prognostic significance of cardiac autonomic neuropathy (CAN) from community-based cohorts with type 2 diabetes assessed using gold standard methods. The aim of this study was to assess these aspects of CAN in the longitudinal observational Fremantle Diabetes Study Phase II (FDS2). METHODS FDS2 participants were screened at baseline using standardised cardiovascular reflex tests (CARTs) of heart rate variation during deep breathing, Valsalva manoeuvre and standing. CAN (no/possible/definite) was assessed from the number of abnormal CARTs. Multinomial regression identified independent associates of CAN status. Cox proportional hazards modelling determined independent baseline predictors of incident heart failure (HF) and ischaemic heart disease (IHD), and all-cause mortality. RESULTS Of 1254 participants assessed for CAN, 86 (6.9%) were outside CART age reference ranges and valid CART data were unavailable for 338 (27.0%). Of the remaining 830 (mean age 62.3 years, 55.3% males, median diabetes duration 7.3 years), 51.0%, 33.7% and 15.3% had no, possible or definite CAN, respectively. Independent associates of definite CAN (longer diabetes duration, higher body mass index and resting pulse rate, antidepressant and antihypertensive therapies, albuminuria, distal sensory polyneuropathy, prior HF) were consistent with those reported previously. In Kaplan-Meier analysis, definite CAN was associated with a lower likelihood of incident IHD and HF versus no/possible CAN (P < 0.001) and there was a graded increase in all-cause mortality risk from no CAN to possible and definite CAN (P < 0.001). When CAN category was added to the most parsimonious models, it was not a significant independent predictor of IHD (P ≥ 0.851) or HF (P ≥ 0.342). Possible CAN (hazard ratio (95% CI) 1.47 (1.01, 2.14), P = 0.046) and definite CAN (2.42 (1.60, 3.67), P < 0.001) increased the risk of all-cause mortality versus no CAN. CONCLUSIONS Routine screening for CAN in type 2 diabetes has limited clinical but some prognostic value.
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Affiliation(s)
- Timothy M E Davis
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia.
- Department of Endocrinology and Diabetes, Fiona Stanley and Fremantle Hospitals, Murdoch, WA, Australia.
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, VIC, Australia.
| | - Eva Tan
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia
| | - Wendy A Davis
- Medical School, Fremantle Hospital, University of Western Australia, PO Box 480, Fremantle, WA, 6959, Australia
- Australian Centre for Accelerating Diabetes Innovations (ACADI), The University of Melbourne, Melbourne, VIC, Australia
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Felício J, Moraes L, Lemos G, Souza Í, Vieira G, Silva L, Queiroz N, Souza AC, Melo F, Neto JFA, Britto H, Lemos M, Santos M, Figueiredo P, Motta AR, Reis M, Caldeira G, Leal V, Piani P, Aquino V, Felício K. High dose cholecalciferol supplementation causing morning blood pressure reduction in patients with type 1 diabetes mellitus and cardiovascular autonomic neuropathy. Sci Rep 2024; 14:6374. [PMID: 38493259 PMCID: PMC10944468 DOI: 10.1038/s41598-024-56934-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/12/2024] [Indexed: 03/18/2024] Open
Abstract
We evaluated the association of cardiovascular autonomic neuropathy (CAN), blood pressure (BP) and Vitamin D (VD) levels before and after high-dose cholecalciferol supplementation (4000/10,000) UI/day) for 12 weeks in patients (N = 67) with type 1 diabetes mellitus (T1DM). Based on this prospective controlled pilot study, patients were divided into group 1 (N = 23 with CAN) and group 2 (N = 44 without CAN). At baseline, group 1 had higher systolic BP (SBP) during sleep (115 ± 14 vs. 107 ± 12 mmHg, p = 0.04) and lower nocturnal dipping (3 ± 5 vs. 8 ± 6%, p = 0.009). Among those with loss of nocturnal dipping, 45.4% (20/44) had CAN, while in normal nocturnal dipping group it occurred only in 13% (3/23) (p = 0.007). Non-dipper group had worse CAN parameters when compared to dipper group [Very low frequency (VLF) (2.5 ± 0.5vs.2.8 ± 0.4 s, p = 0.01), total power (TP) (2.9 ± 0.6 vs. 3.3 ± 0.4 s, p = 0.01), Valsalva coefficient (1.5 ± 0.4 vs. 1.8 ± 0.6, p = 0.06)]. After VD, only group 1 improved CAN parameters [TP (2.5 ± 0.4 vs. 2.8 ± 0.6, p = 0.01) and VLF (2.2 ± 0.4 vs. 2.4 ± 0.5, p = 0.03). Group 1 presented a reduction in morning SBP (120 ± 20 vs. 114 ± 17 mmHg, p = 0.038) and in morning SBP surge (13 ± 13 vs. 5 ± 14, p = 0.04). High-dose VD was associated with improved CAN parameters and reduced awake SBP and morning SBP surge. These findings suggest that VD may benefit patients with cardiovascular autonomic neuropathy. ISRCTN32601947, registration date: 31/07/2017.
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Affiliation(s)
- João Felício
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil.
| | - Lorena Moraes
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Gabriela Lemos
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Ícaro Souza
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Giovana Vieira
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Lilian Silva
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Natércia Queiroz
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Ana Carolina Souza
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Franciane Melo
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - João Felício Abrahão Neto
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Hana Britto
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Manuela Lemos
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Márcia Santos
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Priscila Figueiredo
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Ana Regina Motta
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Melissa Reis
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Gisele Caldeira
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Valéria Leal
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Pedro Piani
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Vitória Aquino
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
| | - Karem Felício
- Endocrinology Division, University Hospital João de Barros Barreto, Federal University of Pará, 4487, Guamá, Belém, Pará, 66073-000, Brazil
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Dillon BR, Ang L, Pop-Busui R. Spectrum of Diabetic Neuropathy: New Insights in Diagnosis and Treatment. Annu Rev Med 2024; 75:293-306. [PMID: 38285516 DOI: 10.1146/annurev-med-043021-033114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
Diabetic neuropathy is a highly prevalent complication of diabetes. It consists of a broad range of neuropathic conditions, such as distal symmetric polyneuropathy and various forms of autonomic neuropathies involving the cardiovascular, gastrointestinal, and urogenital systems. Prevention or diagnosis in early stages of disease is crucial to prevent symptomatic onset and progression, particularly in the absence of current disease-modifying therapies. In this review, we describe the four main types of diabetic neuropathy. We review current understanding with respect to diagnosis and treatment while highlighting knowledge gaps and future directions.
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Affiliation(s)
- Brendan R Dillon
- Department of Medicine, New York University Grossman School of Medicine, New York, NY, USA;
| | - Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan, USA; ,
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Medical School, Ann Arbor, Michigan, USA; ,
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10
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Pop-Busui R. Autonomic diabetic neuropathies: A brief overview. Diabetes Res Clin Pract 2023; 206 Suppl 1:110762. [PMID: 38245325 DOI: 10.1016/j.diabres.2023.110762] [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: 05/03/2023] [Accepted: 05/30/2023] [Indexed: 01/22/2024]
Abstract
This article summarizes the latest epidemiology of diabetic autonomic neuropathy (DAN), and provides a brief overview on epidemiology, current outcomes measures for screening and diagnosis in research and clinical settings, the latest evidence on effective management, and novel perspectives on the impacts of social determinants of health in development and management of DAN. Among the various forms of diabetic neuropathy, distal symmetric polyneuropathy and diabetic autonomic neuropathies, particularly cardiovascular autonomic neuropathy, are by far the most studied. However, emerging data highlight the impact of other forms of autonomic neuropathies such as gastrointestinal and urogenital autonomic neuropathies, on healthcare and patients' reported outcomes [1].
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Affiliation(s)
- Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, USA.
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11
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Hajdu M, Garmpis K, Vértes V, Vorobcsuk-Varga N, Molnár GA, Hejjel L, Wittmann I, Faludi R. Determinants of the heart rate variability in type 1 diabetes mellitus. Front Endocrinol (Lausanne) 2023; 14:1247054. [PMID: 37854193 PMCID: PMC10579906 DOI: 10.3389/fendo.2023.1247054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 09/04/2023] [Indexed: 10/20/2023] Open
Abstract
Background Evaluation of heart rate variability (HRV) detects the early subclinical alterations of the autonomic nervous system. Thus, impaired HRV is the earliest subclinical marker of cardiac autonomic neuropathy (CAN) in type 1 diabetes mellitus (T1DM). Objectives We aimed to explore the HRV parameters in asymptomatic T1DM patients and compare them with the results obtained in healthy subjects. Potential associations between HRV parameters and the established risk factors for CAN and cardiovascular diseases were also investigated. Methods Seventy T1DM patients (38 ± 12 years, 46 females) and 30 healthy subjects were enrolled into the study. For HRV analysis, beat-to-beat heart rate was recorded for 30 min. The less noisy 5-min segment of the recording was analyzed by Bittium Cardiac Navigator HRV analysis software. Time domain, frequency domain, and nonlinear indices were calculated. Results Regarding ratio of low to high frequency component (LF/HF), no differences were found between the two populations (p = 0.227). All the further, time domain, frequency domain, and nonlinear HRV indices were significantly lower in T1DM patients (each p < 0.001). In multiple linear models, disease duration remained the only independent predictor of LF/HF ratio (p = 0.019). HbA1c was found to be significant independent predictor of all further time domain (SDNN, p < 0.001; rMSSD, p < 0.001), frequency domain (VLF, p < 0.001; LF, p = 0.002; HF, p = 0.006; Total Power, p = 0.002), and nonlinear indices (SD1, p = 0.006; SD2, p = 0.007), alone, or in combination with other factors, such as age or body mass index. Conclusion Asymptomatic T1DM patients have significantly reduced overall HRV as compared with healthy subjects, indicating subclinical CAN. Quality of the glycemic control is important determinant of HRV among T1DM patients. This relationship is independent of other risk factors for CAN or cardiovascular diseases.
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Affiliation(s)
- Máté Hajdu
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | | | - Vivien Vértes
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | | | - Gergő Attila Molnár
- 2nd Department of Internal Medicine and Nephrological Center, Medical School, University of Pécs, Pécs, Hungary
| | - László Hejjel
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
| | - István Wittmann
- 2nd Department of Internal Medicine and Nephrological Center, Medical School, University of Pécs, Pécs, Hungary
| | - Réka Faludi
- Heart Institute, Medical School, University of Pécs, Pécs, Hungary
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12
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Rasmussen VF, Thrysøe M, Nyengaard JR, Tankisi H, Karlsson P, Hansen J, Krogh K, Brock C, Kamperis K, Madsen M, Singer W, Vestergaard ET, Kristensen K, Terkelsen AJ. Neuropathy in adolescents with type 1 diabetes: Confirmatory diagnostic tests, bedside tests, and risk factors. Diabetes Res Clin Pract 2023; 201:110736. [PMID: 37276985 DOI: 10.1016/j.diabres.2023.110736] [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: 04/03/2023] [Revised: 05/17/2023] [Accepted: 05/26/2023] [Indexed: 06/07/2023]
Abstract
AIMS To estimate the prevalence of large fiber (LFN), small fiber (SFN), and autonomic neuropathy in adolescents with type 1 diabetes using confirmatory tests known from adults and to identify risk factors and bedside methods for neuropathy. METHODS Sixty adolescents with type 1 diabetes (diabetes duration > five years) and 23 control subjects underwent neurological examination and confirmatory diagnostic tests for neuropathy, including nerve conduction studies, skin biopsies determining intraepidermal nerve fiber density, quantitative sudomotor axon reflex test (QSART), cardiovascular reflex tests (CARTs), and tilt table test. Possible risk factors were analyzed. Bedside tests (biothesiometry, DPNCheck®, Sudoscan, and Vagus®device) were compared with the confirmatory tests using ROC analysis. RESULTS The prevalence of neuropathies in the adolescents with diabetes (mean HbA1c 7.6% (60 mmol/mol)) was as follows: 14% confirmed/26% subclinical LFN, 2% confirmed/25% subclinical SFN, 20% abnormal QSART, 8% abnormal CARTs, and 14% orthostatic hypotension. Higher age, higher insulin dose, previous smoking, and higher triglycerides level were found to increase the relative risk for neuropathy. The bedside tests showed poor to acceptable concordance with the confirmatory tests (all, AUC ≤ 0.75). CONCLUSIONS The diagnostic tests confirmed the presence of neuropathy in adolescents with diabetes and underscore the importance of prevention and screening.
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Affiliation(s)
- Vinni Faber Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Steno Diabetes Center Aarhus, Aarhus University Hospital, Denmark; Department of Pediatrics and Adolescent Medicine, Randers Regional Hospital, Randers, Denmark.
| | - Mathilde Thrysøe
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Jens Randel Nyengaard
- Department of Pathology, Aarhus University Hospital, Aarhus, Denmark; Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Hatice Tankisi
- Department of Neurophysiology, Department of Clinical Medicine, Aarhus University, Denmark
| | - Páll Karlsson
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Core Centre for Molecular Morphology, Section for Stereology and Microscopy, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - John Hansen
- Institute of Health Science and Technology, Aalborg University, Denmark
| | - Klaus Krogh
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Christina Brock
- Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Konstantinos Kamperis
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Denmark
| | - Mette Madsen
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Denmark; Steno Diabetes Center North Denmark, Aalborg, Denmark
| | | | - Esben Thyssen Vestergaard
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Denmark; Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Denmark
| | - Kurt Kristensen
- Steno Diabetes Center Aarhus, Aarhus University Hospital, Denmark
| | - Astrid Juhl Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
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Saleem S, Khandoker AH, Alkhodari M, Hadjileontiadis LJ, Jelinek HF. Investigating the effects of beta-blockers on circadian heart rhythm using heart rate variability in ischemic heart disease with preserved ejection fraction. Sci Rep 2023; 13:5828. [PMID: 37037871 PMCID: PMC10086029 DOI: 10.1038/s41598-023-32963-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/05/2023] [Indexed: 04/12/2023] Open
Abstract
Heart failure is characterized by sympathetic activation and parasympathetic withdrawal leading to an abnormal autonomic modulation. Beta-blockers (BB) inhibit overstimulation of the sympathetic system and are indicated in heart failure patients with reduced ejection fraction. However, the effect of beta-blocker therapy on heart failure with preserved ejection fraction (HFpEF) is unclear. ECGs of 73 patients with HFpEF > 55% were recruited. There were 56 patients in the BB group and 17 patients in the without BB (NBB) group. The HRV analysis was performed for the 24-h period using a window size of 1,4 and 8-h. HRV measures between day and night for both the groups were also compared. Percentage change in the BB group relative to the NBB group was used as a measure of difference. RMSSD (13.27%), pNN50 (2.44%), HF power (44.25%) and LF power (13.53%) showed an increase in the BB group relative to the NBB group during the day and were statistically significant between the two groups for periods associated with high cardiac risk during the morning hours. LF:HF ratio showed a decrease of 3.59% during the day. The relative increase in vagal modulated RMSSD, pNN50 and HF power with a decrease in LF:HF ratio show an improvement in the parasympathetic tone and an overall decreased risk of a cardiac event especially during the morning hours that is characterized by a sympathetic surge.
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Affiliation(s)
- Shiza Saleem
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates.
| | - Ahsan H Khandoker
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
| | - Mohanad Alkhodari
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Cardiovascular Clinical Research Facility, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Leontios J Hadjileontiadis
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
| | - Herbert F Jelinek
- Department of Biomedical Engineering, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Healthcare Engineering Innovation Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
- Biotechnology Center, Khalifa University, 127788, Abu Dhabi, United Arab Emirates
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14
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Ang L, Mizokami-Stout K, Eid SA, Elafros M, Callaghan B, Feldman EL, Pop-Busui R. The conundrum of diabetic neuropathies-Past, present, and future. J Diabetes Complications 2022; 36:108334. [PMID: 36306721 PMCID: PMC10202025 DOI: 10.1016/j.jdiacomp.2022.108334] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/01/2022] [Accepted: 10/01/2022] [Indexed: 10/31/2022]
Abstract
Diabetic neuropathy (DN) remains arguably the most prevalent chronic complication in people with both type 1 and type 2 diabetes, including in youth, despite changes in the current standards of clinical care. Additionally, emerging evidence demonstrates that neuropathy affects a large proportion of people with undiagnosed diabetes and/or prediabetes, as well as those with obesity. Here we summarize the latest epidemiology of DN, recent findings regarding the pathophysiology of the disease, as well as current outcome measures for screening and diagnosis, in research and clinical settings. The authors discuss novel perspectives on the impact of social determinants of health in DN development and management, and the latest evidence on effective therapies, including pharmacological and nonpharmacological therapies for neuropathic pain. Throughout the publication, we identify knowledge gaps and the need for future funding to address these gaps, as well as needs to advocate for a personalized care approach to reduce the burden of DN and optimize quality of life for all affected individuals.
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Affiliation(s)
- Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Kara Mizokami-Stout
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America; Ann Arbor Veteran Affairs Hospital, Ann Arbor, MI, United States of America
| | - Stephanie A Eid
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America
| | - Melissa Elafros
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America
| | - Brian Callaghan
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States of America
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America.
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15
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Blonde L, Umpierrez GE, Reddy SS, McGill JB, Berga SL, Bush M, Chandrasekaran S, DeFronzo RA, Einhorn D, Galindo RJ, Gardner TW, Garg R, Garvey WT, Hirsch IB, Hurley DL, Izuora K, Kosiborod M, Olson D, Patel SB, Pop-Busui R, Sadhu AR, Samson SL, Stec C, Tamborlane WV, Tuttle KR, Twining C, Vella A, Vellanki P, Weber SL. American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update. Endocr Pract 2022; 28:923-1049. [PMID: 35963508 PMCID: PMC10200071 DOI: 10.1016/j.eprac.2022.08.002] [Citation(s) in RCA: 154] [Impact Index Per Article: 77.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 08/01/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers. METHODS The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development. RESULTS This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes. CONCLUSIONS This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.
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Affiliation(s)
| | | | - S Sethu Reddy
- Central Michigan University, Mount Pleasant, Michigan
| | | | | | | | | | | | - Daniel Einhorn
- Scripps Whittier Diabetes Institute, La Jolla, California
| | | | | | - Rajesh Garg
- Lundquist Institute/Harbor-UCLA Medical Center, Torrance, California
| | | | | | | | | | | | - Darin Olson
- Colorado Mountain Medical, LLC, Avon, Colorado
| | | | | | - Archana R Sadhu
- Houston Methodist; Weill Cornell Medicine; Texas A&M College of Medicine; Houston, Texas
| | | | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | | | - Katherine R Tuttle
- University of Washington and Providence Health Care, Seattle and Spokane, Washington
| | | | | | | | - Sandra L Weber
- University of South Carolina School of Medicine-Greenville, Prisma Health System, Greenville, South Carolina
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16
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Blair Y, Wessells H, Pop-Busui R, Ang L, Sarma AV. Urologic complications in diabetes. J Diabetes Complications 2022; 36:108288. [PMID: 36088680 PMCID: PMC10783766 DOI: 10.1016/j.jdiacomp.2022.108288] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Accepted: 08/24/2022] [Indexed: 11/24/2022]
Abstract
Urologic complications such as bladder and sexual dysfunction among men and women with diabetes have received relatively little attention. This is despite emerging evidence that demonstrates that urologic complications increase with age in the general population and are more common in individuals with diabetes compared to those without diabetes. Here we summarize the latest information about the epidemiology of urologic complications in the setting of diabetes and the most recent findings regarding pathophysiology. In addition, we identify knowledge gaps and need for future funding to address these gaps that will reduce the burden of urologic complications in diabetes and optimize quality of life for all individuals affected by it.
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Affiliation(s)
- Yooni Blair
- Department of Urology, University of Michigan, Ann Arbor, MI, United States of America
| | - Hunter Wessells
- Department of Urology, University of Washington, Seattle, WA, United States of America
| | - Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Lynn Ang
- Department of Internal Medicine, Division of Metabolism, Endocrinology, and Diabetes, University of Michigan, Ann Arbor, MI, United States of America
| | - Aruna V Sarma
- Department of Urology, University of Michigan, Ann Arbor, MI, United States of America.
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17
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Menduni M, D'Amato C, Leoni M, Izzo V, Staltari M, Greco C, Abbatepassero A, Seminara G, D'Ippolito I, Lauro D, Spallone V. Clinical scoring systems for the risk of cardiovascular autonomic neuropathy in type 1 and type 2 diabetes: a simple tool. J Peripher Nerv Syst 2022; 27:259-270. [PMID: 36029134 DOI: 10.1111/jns.12510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 08/01/2022] [Accepted: 08/19/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS This study was aimed at developing a clinical risk score for cardiovascular autonomic neuropathy (CAN) for type 1 and type 2 diabetes. METHODS In a retrospective cross-sectional one-centre study in an unselected population, 115 participants with type 1 diabetes (age 41.1±12.2 years), and 161 with type 2 diabetes (age 63.1±8.9 years), well-characterised for clinical variables, underwent standard cardiovascular reflex tests (CARTs). Strength of associations of confirmed CAN (based on 2 abnormal CARTs) with clinical variables was used to build a CAN risk score. RESULTS CAN risk score was based on resting heart rate, HbA1c, retinopathy, nephropathy, cardiovascular disease in both type 1 and type 2 diabetes, and on HDL cholesterol, systolic blood pressure, and smoking in type 1 diabetes or insulin treatment and physical activity in type 2 diabetes (range 0-10). In type 1 diabetes, CAN risk score showed an area under the ROC curve (AUC) of 0.890±0.034, and at cut-off of 4 sensitivity of 88%, specificity of 74.4%, and negative predictive value (NPV) of 95.7% for confirmed CAN. In type 2 diabetes, CAN risk score showed an AUC of 0.830±0.051 and at the cut-off of 4 sensitivity and specificity of 78.6% and 73.5%, respectively, and NPV of 97.3% for confirmed CAN. INTERPRETATION These newly developed CAN risk scores are accessible in clinical practice and, if confirmed in a validation study, they might identify asymptomatic individuals with diabetes at greater risk of CAN to be referred to CARTs, thus limiting the burden of a universal screening. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marika Menduni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Cinzia D'Amato
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Martina Leoni
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Valentina Izzo
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Mariateresa Staltari
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Carla Greco
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Andrea Abbatepassero
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Giuseppe Seminara
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Ilenia D'Ippolito
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Davide Lauro
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
| | - Vincenza Spallone
- Department of Systems Medicine, Endocrinology Section, University of Rome Tor Vergata, Rome, Italy
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18
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Liu B, Zhao Y, Zhang H. The Effect of Autonomic Nervous System Dysfunction on the Progression of Primary Open-Angle Glaucoma. Int J Gen Med 2022; 15:4565-4573. [PMID: 35528285 PMCID: PMC9075998 DOI: 10.2147/ijgm.s362275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 04/22/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose To study the effect of autonomic nervous system (ANS) dysfunction on glaucoma progression in patients with primary open angle glaucoma (POAG). Patients and Methods A retrospective study of 40 cases of POAG patients who underwent regular reexamination for more than 3 years was performed. All participants were subjected to heart-rate variability (HRV) assessment. Patients were divided equally into the lowest and highest HRV groups according to the standard deviation value of the qualified normal to normal intervals (SDNN), a representative indicator of HRV. The lower the HRV, the more severe the ANS dysfunction with sympathetic predominance. Visual field (VF) parameters and retinal nerve fiber layer (RNFL) thickness were used to evaluate and compare the progression of glaucoma damage between the two groups. Results There were 20 cases in the lowest HRV group and 20 cases in the highest HRV group. The thinning rate of RNFL in the lowest HRV group was significantly faster than that in the highest HRV group (1.44±1.58 vs 0.29±0.56 μm/year, P=0.00), accompanied by greater fluctuation of intraocular pressure (IOP) (P=0.04), lower diastolic blood pressure (P=0.01), mean blood pressure (P=0.04), and lower mean ocular perfusion pressure (P=0.04). Meanwhile, the incidence of central VF defects in the lowest HRV group was significantly higher than that in the highest HRV group (65.0% vs 30%, P=0.03). Linear regression analysis showed that there was a significant correlation between SDNN and the thickness loss rate of RNFL (P=0.01). Conclusion POAG patients with lower HRV, which reflects ANS dysfunction with sympathetic predominance, presented faster glaucoma progression than patients with higher HRV. The more rapid progression of POAG with lower HRV may be explained by IOP and vascular risk factors.
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Affiliation(s)
- Binbin Liu
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Yin Zhao
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
| | - Hong Zhang
- Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China
- Correspondence: Hong Zhang, Department of Ophthalmology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People’s Republic of China, Tel +86 027 13971679079, Email
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Aso Y. Updates in diabetic neuropathy: A call for new diagnostic and treatment approaches. J Diabetes Investig 2022; 13:432-434. [PMID: 34779155 PMCID: PMC8902406 DOI: 10.1111/jdi.13711] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 11/10/2021] [Accepted: 11/11/2021] [Indexed: 12/13/2022] Open
Affiliation(s)
- Yoshimasa Aso
- Department of Endocrinology and MetabolismDokkyo Medical UniversityShimotsugaJapan
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Wang J, Xu Z, Lv K, Ye Y, Luo D, Wan L, Zhou F, Yu A, Wang S, Liu J, Gao L. The Predictive Value of Serum Calcium on Heart Rate Variability and Cardiac Function in Type 2 Diabetes Patients. Front Endocrinol (Lausanne) 2022; 13:864008. [PMID: 35498438 PMCID: PMC9047897 DOI: 10.3389/fendo.2022.864008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Cardiovascular autonomic neuropathy (CAN) is common in patients with type 2 diabetes mellitus (T2DM), mainly presented as decreased heart rate variability (HRV) which often leads to cardiac death. However, HRV measurement is not convenient in most clinics. Therefore, identifying high-risk patients for CAN in diabetes with easier measurements is crucial for the early intervention and prevention of catastrophic consequences. METHODS In this cross-sectional study, 675 T2DM patients with normocalcemia were selected. Of these, they were divided into two groups: normal HRV group (n = 425, 100 ms≤ SDNN ≤180 ms) vs. declined HRV group (n = 250, SDNN <100 ms). All patients' clinical data were collected and the correlation of clinical variables with HRV were analyzed by correlation and logistic regression analysis. The area below the ROC curve was used to evaluate the predictive performance of serum calcium on HRV. RESULTS In this study, declines in HRV were present in 37.0% of T2DM patients. Significant differences in albumin-adjusted serum calcium levels (CaA) (8.86 ± 0.27 vs. 9.13 ± 0.39 mg/dl, p <0.001) and E/A (0.78 ± 0.22 vs. 0.83 ± 0.26, p = 0.029) were observed between declined HRV and normal HRV groups. Bivariate linear correlation analysis showed that CaA and E/A were positively correlated with HRV parameters including SDNN (p < 0.001), SDNN index (p < 0.001), and Triangle index (p < 0.05). The AUC in the ROC curve for the prediction of CaA on HRV was 0.730 (95% CI (0.750-0.815), p < 0.001). The cutoff value of CaA was 8.87 mg/dl (sensitivity 0.644, specificity 0.814). The T2DM patients with CaA <8.87 mg/dl had significantly lower HRV parameters (SDNN, SDNN index, rMSSD, and triangle index) than those with CaA ≥8.87 mg/dl (p < 0.01, respectively). Multivariate logistic regression analysis showed a significantly increased risk of declined HRV in subjects with CaA level <8.87 mg/dl [OR (95% CI), 0.049 (0.024-0.099), p < 0.001]. CONCLUSIONS Declined HRV is associated with a lower CaA level and worse cardiac function. The serum calcium level can be used for risk evaluation of declined HRV in T2DM patients even within the normocalcemic range.
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Affiliation(s)
- Junyi Wang
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zihui Xu
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Kang Lv
- Shenzhen University, College of Big Data and Internet, Shenzhen, China
| | - Yingchun Ye
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Deng Luo
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Wan
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Fen Zhou
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ailin Yu
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shuo Wang
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jingcheng Liu
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
| | - Ling Gao
- Department of Endocrinology & Metabolism, Renmin Hospital of Wuhan University, Wuhan, China
- *Correspondence: Ling Gao,
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