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Chrysant SG. The Option of Chronotherapy of Hypertension. Cardiol Rev 2024:00045415-990000000-00234. [PMID: 38506526 DOI: 10.1097/crd.0000000000000644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
The aim of the present paper is to explore the option of chronotherapy of hypertension and its effectiveness in blood pressure (BP) lowering compared with its standard daily treatment. The treatment of BP has gone through many different schemes over the years. From no treatment in the early 1930s, to step care, to multiple drug combinations, or to single daily drug combinations with 2-3 drugs, still BP is not well controlled in a significant number of patients. Recently, the role of the circadian rhythm in the treatment of hypertension has been tested by several studies comparing the evening versus the morning drug administration with no clear evidence of superiority of either mode of drug administration. However, in cases of morning surge of BP, nocturnal hypertension, and renal disease, the evening drug administration has been more effective than the morning drug administration, and thus, more preferable. In order to get a better perspective on this approach of hypertension treatment, a Medline search of the English literature was contacted between 2010 and 2023 using the terms BP control, circadian rhythm, morning drug administration, evening drug administration, and 38 pertinent papers were selected for analysis. Careful review of the selected papers showed that chronotherapy of hypertension is effective. However, the overall effectiveness of evening drug administration compared with the morning administration is not significantly more effective compared to the morning administration and more work is needed in this field.
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Affiliation(s)
- Steven G Chrysant
- From the Department of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Gavan DE, Gavan A, Bondor CI, Florea B, Bowling FL, Inceu GV, Colobatiu L. SUDOSCAN, an Innovative, Simple and Non-Invasive Medical Device for Assessing Sudomotor Function. SENSORS (BASEL, SWITZERLAND) 2022; 22:7571. [PMID: 36236669 PMCID: PMC9573142 DOI: 10.3390/s22197571] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 09/29/2022] [Accepted: 10/04/2022] [Indexed: 06/16/2023]
Abstract
Diabetic autonomic neuropathy is probably the most undiagnosed but serious complication of diabetes. The main objectives were to assess the prevalence of peripheral and autonomic neuropathy in a population of diabetic patients, analyze it in a real-life outpatient unit scenario and determine the feasibility of performing SUDOSCAN tests together with widely used tests for neuropathy. A total of 33 patients were included in the study. Different scoring systems (the Toronto Clinical Neuropathy Score-TCNS; the Neuropathy Disability Score-NDS; and the Neuropathy Symptom Score-NSS) were applied to record diabetic neuropathy (DN), while the SUDOSCAN medical device was used to assess sudomotor function, detect diabetic autonomic neuropathy and screen for cardiac autonomic neuropathy (CAN). Fifteen (45.5%) patients had sudomotor dysfunction. The SUDOSCAN CAN risk score was positively correlated with the hands' electrochemical sweat conductance (ESC), diastolic blood pressure (DBP), the level of the glycated hemoglobin, as well as with the TCNS, NDS and NSS. Performing SUDOSCAN tests together with other tests for DN proved to be a feasible approach that could be used in daily clinical practice in order to screen for DN, as well as for the early screening of CAN, before more complex and time-consuming tests.
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Affiliation(s)
- Dana Elena Gavan
- Clinic of Podiatry, 10 Iuliu Moldovan Street, 400348 Cluj-Napoca, Romania
| | - Alexandru Gavan
- Department of Medical Devices, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 4 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Cosmina Ioana Bondor
- Department of Medical Informatics and Biostatistics, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 6 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
| | - Bogdan Florea
- Clinic of Podiatry, 10 Iuliu Moldovan Street, 400348 Cluj-Napoca, Romania
| | - Frank Lee Bowling
- Faculty of Medicine, University of Manchester, Oxford Road, Manchester M13 9PL, UK
- Department of Vascular Surgery and Reconstructive Microsurgery, “Victor Babes” University of Medicine and Pharmacy, 2 Eftimie Murgu Square, 300041 Timisoara, Romania
| | - Georgeta Victoria Inceu
- Department of Diabetes, Nutrition and Metabolical Diseases, Faculty of Medicine, Iuliu Hatieganu University of Medicine and Pharmacy, 2–4 Clinicilor Street, 400006 Cluj-Napoca, Romania
| | - Liora Colobatiu
- Department of Medical Devices, Faculty of Pharmacy, Iuliu Hatieganu University of Medicine and Pharmacy, 4 Louis Pasteur Street, 400349 Cluj-Napoca, Romania
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Călin P, Viorel M, Luchiana P, Mihaela C, Lavinia P. Masked nocturnal hypertension as a result of high prevalence of non-dippers among apparently well-controlled hypertensive patients with type 2 diabetes mellitus: data from a prospective study. Diabetol Metab Syndr 2022; 14:130. [PMID: 36109761 PMCID: PMC9479407 DOI: 10.1186/s13098-022-00899-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 08/29/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) in patients with diabetes mellitus (DM) and hypertension (HTN) show the dipping patterns, identify masked uncontrolled hypertension (MUCH), and demonstrate the effectiveness of the blood pressure (BP) treatment. MUCH is associated with a two-fold higher risk of adverse events. Prevalence in patients with DM is between 13.3 and 66.4%. Our study aims to investigate the prevalence of MUCH and the BP patterns in a population of apparently well-controlled hypertensive patients with type 2 DM (T2DM). A second aspect was the assessment of the effectiveness of antihypertensive treatment. METHODS One hundred and sixty-three consecutively treated hypertensive patients with T2DM and an office BP between 130-139 and 80-89 mmHg performed a 24 h ABPM. The circadian BP variation, the presence of MUCH, and the correlations with the treatment were assessed. RESULTS There were 75 dippers (46.02%), 77 non-dippers (47.23%), 4 reverse dippers (2.45%), and 7 extreme dippers (4.30%). Eighty-one patients (77 non-dippers + 4 reverse dippers; 49.7%) had isolated nocturnal MUCH according to the mean night ABPM criteria. Dippers and extreme dippers (75 dippers + 7 extreme dippers; 51.3%) did not have any MUCH criteria. The patients took, on an average, 3 antihypertensive drugs with no difference between those with controlled HTN and the isolated nocturnal MUCH group. Significant factors associated with isolated nocturnal MUCH and a non-dipping BP pattern included age > 65 years (OR = 1.9), DM duration > 10 years (OR = 1.4), HTN duration > 6.5 years (OR = 1.2), obesity (OR = 1.6), and cardiovascular comorbidities (OR = 1.4). CONCLUSIONS The current study shows that half of the treated hypertensive patients with T2DM and office clinical normotension are non-dippers or reverse dippers. They experience isolated nocturnal MUCH due to their elevated nocturnal BP values, which comply with the actual definition of masked nocturnal hypertension. Bedtime chronotherapy in those patients could be linked to better effectiveness of antihypertensive treatment during the night with the important goal of reducing cardiovascular and cerebrovascular adverse events. ABPM should be performed in hypertensive patients with DM for better risk stratification and more effective control of HTN.
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Affiliation(s)
- Pop Călin
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
- Faculty of Medicine Arad, “Vasile Goldis” University, 310025 Arad, Romania
| | - Manea Viorel
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Pruna Luchiana
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Cosma Mihaela
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
| | - Pop Lavinia
- Emergency Clinical County Hospital Baia Mare, Str George Cosbuc Nr 31, 430130 Baia Mare, Romania
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Hjortkjær HØ, Persson F, Theilade S, Winther SA, Tofte N, Ahluwalia TS, Rossing P. Non-dipping and higher nocturnal blood pressure are associated with risk of mortality and development of kidney disease in type 1 diabetes. J Diabetes Complications 2022; 36:108270. [PMID: 35964524 DOI: 10.1016/j.jdiacomp.2022.108270] [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: 03/30/2022] [Revised: 07/02/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022]
Abstract
AIMS People with type 1 diabetes have increased risk of cardiovascular (CV) and kidney disease. A 24-hour ambulatory blood pressure (BP) measurement (ABPM) examines diurnal variations in BP. We aimed to determine the prognostic significance of blunted decrease in nocturnal systolic BP of <10 % (non-dipping of nocturnal BP) for CV- and kidney disease and all-cause mortality in type 1 diabetes. METHODS From 2009 to 2011, at Steno Diabetes Center Copenhagen, 654 participants with type 1 diabetes had 24-hour ABPM obtained with a tonometric wrist-watch device (BPro, HealthStats, Singapore). In 2017, outcomes (composite CV endpoint; all-cause mortality; decline in estimated glomerular filtration rate (eGFR) ≥30 %; end-stage kidney disease (ESKD); and a composite kidney endpoint including decline in eGFR ≥30 %, ESKD and all-cause mortality) were registered. Hazard Ratios (HR) were calculated using Cox regressions. RESULTS Participants were mean ± SD 55 ± 13 years old and had median (IQR) 35 (24-44) years diabetes duration. Mean daytime and nocturnal systolic BP were 133 ± 16 and 121 ± 16 mmHg while 337 (52 %) participants demonstrated non-dipping. After CV risk factor adjustments, non-dipping was associated with all-cause mortality (HR 2.12 (1.09-4.11), p = 0.03) and the composite kidney endpoint (HR 1.92 (1.23-3.00), p = 0.004). CONCLUSIONS Non-dipping entailed increased risk of all-cause mortality and kidney disease in type 1 diabetes.
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Affiliation(s)
| | | | - Simone Theilade
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Signe A Winther
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Novo Nordisk A/S, Søborg, Denmark
| | - Nete Tofte
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Novo Nordisk A/S, Søborg, Denmark
| | - Tarunveer S Ahluwalia
- Steno Diabetes Center Copenhagen, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
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Sultana R, Pati AK. Twenty-four-hour and nocturnal ambulatory blood pressure variability patterns in diabetics and hypothyroid patients: Looking through different temporal windows. BIOL RHYTHM RES 2022. [DOI: 10.1080/09291016.2022.2044632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Razia Sultana
- Department of Zoology, SKM Govt College, Raipur, India
| | - Atanu Kumar Pati
- School of Life Sciences, Pt. Ravishankar Shukla University, Raipur, India
- Odisha State Higher Education Council, Department of Higher Education, Government of Odisha, Bhubaneswar, India
- Kalinga Institute of Social Sciences, Deemed to Be University, Bhubaneswar, India
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Hermida RC, Hermida-Ayala RG, Smolensky MH, Mojón A, Crespo JJ, Otero A, Ríos MT, Domínguez-Sardiña M, Fernández JR. Does Timing of Antihypertensive Medication Dosing Matter? Curr Cardiol Rep 2020; 22:118. [DOI: 10.1007/s11886-020-01353-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Helleputte S, De Backer T, Lapauw B, Shadid S, Celie B, Van Eetvelde B, Vanden Wyngaert K, Calders P. The relationship between glycaemic variability and cardiovascular autonomic dysfunction in patients with type 1 diabetes: A systematic review. Diabetes Metab Res Rev 2020; 36:e3301. [PMID: 32073212 DOI: 10.1002/dmrr.3301] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 01/28/2020] [Accepted: 02/04/2020] [Indexed: 02/06/2023]
Abstract
Rigorous glycaemic control-reflected by low HbA1c goals-is of the utmost importance in the prevention and management of complications in patients with type 1 diabetes mellitus (T1DM). However, previous studies suggested that short-term glycaemic variability (GV) is also important to consider as excessive glucose fluctuations may have an additional impact on the development of diabetic complications. The potential relationship between GV and the risk of cardiovascular autonomic neuropathy (CAN), a clinical expression of cardiovascular autonomic dysfunction, is of increasing interest. This systematic review aimed to summarize existing evidence concerning the relationship between GV and cardiovascular autonomic dysfunction in T1DM. An electronic database search of Medline (PubMed), Web of Science and Embase was performed up to October 2019. There were no limits concerning year of publication. Methodological quality was evaluated using the Newcastle Ottawa Scale for observational studies. Six studies (four cross-sectional and two prospective cohorts) were included. Methodological quality of the studies varied from level C to A2. Two studies examined the association between GV and heart rate variability (HRV), and both found significant negative correlations. Regarding cardiovascular autonomic reflex tests (CARTs), two studies did not, while two other studies did find significant associations between GV parameters and CART scores. However, associations were attenuated after adjusting for covariates such as HbA1c, age and disease duration. In conclusion, this systematic review found some preliminary evidence supporting an association between GV and cardiovascular autonomic dysfunction in T1DM. Hence, uncertainty remains whether high GV can independently contribute to the onset or progression of CAN. The heterogeneity in the methodological approach made it difficult to compare different studies. Future studies should therefore use uniformly evaluated continuous glucose monitoring-derived parameters of GV, while standardized assessment of HRV, CARTs and other potential cardiac autonomic function parameters is needed for an unambiguous definition of CAN.
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Affiliation(s)
- Simon Helleputte
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Tine De Backer
- Department of Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Bruno Lapauw
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Samyah Shadid
- Department of Endocrinology, Ghent University Hospital, Ghent, Belgium
| | - Bert Celie
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Birgit Van Eetvelde
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Karsten Vanden Wyngaert
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Patrick Calders
- Department of Rehabilitation Sciences, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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Almeida FAD. Nocturnal Blood Pressure Dipping and the Autonomic Nervous System. Arq Bras Cardiol 2020; 114:716-717. [PMID: 32491000 DOI: 10.36660/abc.20200280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Hjortkjær HØ, Jensen T, Hilsted J, Mogensen UM, Corinth H, Rossing P, Sigvardsen PE, Fuchs A, Kühl JT, Nordestgaard BG, Køber L, Kofoed KF. Cardiac ventricular sizes are reduced in patients with long-term, normoalbuminuric type 1 diabetes compared to the non-diabetic background population. Diab Vasc Dis Res 2019; 16:289-296. [PMID: 30599765 DOI: 10.1177/1479164118819961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIMS Type 1 diabetes entails increased cardiovascular morbidity and cardiac chamber sizes are associated with cardiovascular disease. The aim of this study was to compare cardiac chamber sizes in normoalbuminuric persons with type 1 diabetes to a background population without diabetes. METHODS In a cross-sectional study, we examined 71 normoalbuminuric persons with long-term type 1 diabetes without known cardiovascular disease using cardiac multi-detector computed tomography. Cardiac chamber sizes and left ventricular remodelling were compared to persons without diabetes from the Copenhagen General Population Study. RESULTS Participants were median (interquartile range) 54 (48-60) (type 1 diabetes) and 57 (50-64) (without diabetes) years old and 59% were men (both groups). Participants with type 1 diabetes had smaller left ventricular mass (-3.5 g/m2, 95% confidence interval -5.8 to -1.3) and left (-4.0 mL/m2, 95% confidence interval -6.9 to -1.0) and right (-11.7 mL/m2, 95% confidence interval -15.4 to -7.9) ventricular volumes in multivariable analyses (adjusted for age, sex, body composition, blood pressure and antihypertensive medication), but no differences in atrial volumes. CONCLUSION Persons with long-term type 1 diabetes had smaller left ventricular mass and biventricular volumes, yet similar atrial sizes, compared to a background population without diabetes. These findings may reflect subclinical development of diabetic cardiomyopathy.
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Affiliation(s)
- Henrik Ø Hjortkjær
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 2 Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tonny Jensen
- 2 Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jannik Hilsted
- 2 Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Ulrik M Mogensen
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helle Corinth
- 2 Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Rossing
- 3 Steno Diabetes Center Copenhagen, Copenhagen, Denmark
- 4 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per E Sigvardsen
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Andreas Fuchs
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - J Tobias Kühl
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Børge G Nordestgaard
- 4 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- 5 Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital, Herlev, Denmark
| | - Lars Køber
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 4 Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus F Kofoed
- 1 Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- 6 Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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10
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Hjortkjær HØ, Jensen T, Hilsted J, Mogensen UM, Corinth H, Rossing P, Køber L, Kofoed KF. Left ventricular remodelling and cardiac chamber sizes in long-term, normoalbuminuric type 1 diabetes patients with and without cardiovascular autonomic neuropathy. J Diabetes Complications 2019; 33:171-177. [PMID: 30355473 DOI: 10.1016/j.jdiacomp.2018.10.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/03/2018] [Accepted: 10/09/2018] [Indexed: 01/19/2023]
Abstract
AIMS Type 1 diabetes is associated with increased cardiovascular (CV) morbidity and mortality, and cardiovascular autonomic neuropathy (CAN) is an important CV risk factor. The study aimed to explore associations between CAN and altered cardiac chamber sizes in persons with type 1 diabetes. METHODS This was a cross-sectional study of 71 asymptomatic, normoalbuminuric participants with long-term type 1 diabetes (39 with CAN, determined by >1 abnormal autonomic function test) examined with cardiac multi detector computed tomography scans, which allowed measurements of left ventricular mass and all four cardiac chamber volumes. Cardiac chambers were indexed according to body surface area (ml/m2 or g/m2). RESULTS Persons with and without CAN had mean ± SD age of 57 ± 7 and 50 ± 8 years (p < 0.001) and diabetes duration of 36 ± 11 and 32 ± 9 years (p < 0.05), respectively. Increasing autonomic dysfunction, evaluated by decrease in heart rate variability during deep breathing (in beats per minute), was associated with larger right (-0.5, 95% CI -1.0 to -0.0, p < 0.05) and trend towards larger left (-0.4, 95% CI -0.8-0.0, p < 0.1) ventricular volumes in multivariable linear regression. CONCLUSIONS Our results suggest that impaired autonomic function may be associated with modest enlargement of ventricular volumes; this might be an early sign of progression towards heart failure.
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Affiliation(s)
- Henrik Ø Hjortkjær
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jannik Hilsted
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulrik M Mogensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Helle Corinth
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Denmark
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11
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Spallone V. Update on the Impact, Diagnosis and Management of Cardiovascular Autonomic Neuropathy in Diabetes: What Is Defined, What Is New, and What Is Unmet. Diabetes Metab J 2019; 43:3-30. [PMID: 30793549 PMCID: PMC6387879 DOI: 10.4093/dmj.2018.0259] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 02/01/2019] [Indexed: 12/15/2022] Open
Abstract
The burden of diabetic cardiovascular autonomic neuropathy (CAN) is expected to increase due to the diabetes epidemic and its early and widespread appearance. CAN has a definite prognostic role for mortality and cardiovascular morbidity. Putative mechanisms for this are tachycardia, QT interval prolongation, orthostatic hypotension, reverse dipping, and impaired heart rate variability, while emerging mechanisms like inflammation support the pervasiveness of autonomic dysfunction. Efforts to overcome CAN under-diagnosis are on the table: by promoting screening for symptoms and signs; by simplifying cardiovascular reflex tests; and by selecting the candidates for screening. CAN assessment allows for treatment of its manifestations, cardiovascular risk stratification, and tailoring therapeutic targets. Risk factors for CAN are mainly glycaemic control in type 1 diabetes mellitus (T1DM) and, in addition, hypertension, dyslipidaemia, and obesity in type 2 diabetes mellitus (T2DM), while preliminary data regard glycaemic variability, vitamin B12 and D changes, oxidative stress, inflammation, and genetic biomarkers. Glycaemic control prevents CAN in T1DM, whereas multifactorial intervention might be effective in T2DM. Lifestyle intervention improves autonomic function mostly in pre-diabetes. While there is no conclusive evidence for a disease-modifying therapy, treatment of CAN manifestations is available. The modulation of autonomic function by SGLT2i represents a promising research field with possible clinical relevance.
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Affiliation(s)
- Vincenza Spallone
- Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
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12
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Abstract
PURPOSE OF REVIEW This review considers the relationship between abnormal blood pressure (BP) variability and autonomic dysfunction through an attempt to answer questions about its clinical relevance and pertinence to diabetes and cardiovascular autonomic neuropathy (CAN) and which therapeutic measures can lessen its cardiovascular impact. RECENT FINDINGS Office, ambulatory, and home BP monitoring identify posture-related, circadian, short-term, and long-term BP variabilities. Abnormal BP variability is a risk marker for organ damage, mortality, and cardiovascular events. Moreover, BP variability changes are common in diabetes and associated with CAN and possibly exacerbated by comorbidities like nephropathy, obstructive sleep apnoea syndrome, and chronic pain. The prognostic role of nondipping and reverse dipping is well documented in diabetes. Some findings suggest the possibility of restoring dipping with the dosage time of antihypertensive agents. Diabetes is a favorable scenario for altered BP variability, which might mediate the harmful effects of CAN. Preliminary data suggest the protective effect of targeting BP variability. However, further longitudinal outcome studies are needed. In the meantime, BP variability measures and practical expedients in antihypertensive treatment should be implemented in diabetes.
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Affiliation(s)
- Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, 00133, Rome, Italy.
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13
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Abstract
PURPOSE OF REVIEW Given the emerging knowledge that circadian rhythmicity exists in every cell and all organ systems, there is increasing interest in the possible benefits of chronotherapy for many diseases. There is a well-documented 24-h pattern of blood pressure with a morning surge that may contribute to the observed morning increase in adverse cardiovascular events. Historically, antihypertensive therapy involves morning doses, usually aimed at reducing daytime blood pressure surges, but an absence of nocturnal dipping blood pressure is also associated with increased cardiovascular risk. RECENT FINDINGS To more effectively reduce nocturnal blood pressure and still counteract the morning surge in blood pressure, a number of studies have examined moving one or more antihypertensives from morning to bedtime dosing. More recently, such studies of chronotherapy have studied comorbid populations including obstructive sleep apnea, chronic kidney disease, or diabetes. Here, we summarize major findings from recent research in this area (2013-2017). In general, nighttime administration of antihypertensives improved overall 24-h blood pressure profiles regardless of disease comorbidity. However, inconsistencies between studies suggest a need for more prospective randomized controlled trials with sufficient statistical power. In addition, experimental studies to ascertain mechanisms by which chronotherapy is beneficial could aid drug design and guidelines for timed administration.
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Affiliation(s)
- N P Bowles
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA.
| | - S S Thosar
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
| | - M X Herzig
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
| | - S A Shea
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
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Hjortkjær HØ, Jensen T, Hilsted J, Corinth H, Mogensen UM, Køber L, Fuchs A, Nordestgaard BG, Kofoed KF. Possible early detection of coronary artery calcium progression in type 1 diabetes: A case-control study of normoalbuminuric type 1 diabetes patients and matched controls. Diabetes Res Clin Pract 2018; 141:18-25. [PMID: 29679631 DOI: 10.1016/j.diabres.2018.04.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 04/05/2018] [Accepted: 04/12/2018] [Indexed: 01/06/2023]
Abstract
AIMS Coronary artery calcium (CAC) is associated with cardiovascular (CV) disease and progression of CAC is an independent predictor of mortality. Type 1 diabetes is associated with increased CV risk, especially in persons with cardiovascular autonomic neuropathy (CAN). This study aimed to examine whether short-term progression of CAC is increased in persons with type 1 diabetes compared to matched controls and if CAN increases risk of CAC progression. METHODS Fifty-three normoalbuminuric persons with long-term type 1 diabetes (20 with CAN) were matched in a 1:2 ratio with 106 controls without diabetes according to age, sex and baseline CAC. All were examined twice with cardiac computed tomography scans. Progression of CAC was defined as a value ≥2.5 between the square root-transformed values of follow-up and baseline CAC volume scores. RESULTS The participants were examined median (interquartile range) of 25 (23-27) months (type 1 diabetes) and 29 (25-33) months (controls) apart. In multivariable logistic regression, participants with type 1 diabetes had an odds ratio of 3.3 (95% CI 1.3-8.2, p = 0.01) for CAC progression. CAN did not increase progression of CAC (p = 0.64). CONCLUSIONS Progression of CAC was increased in well-treated, normoalbuminuric persons with type 1 diabetes compared to matched controls without diabetes, suggesting that type 1 diabetes is a risk factor for short-term progression. This finding could explain some of the increased morbidity and mortality observed in persons with type 1 diabetes, but it does not specifically explain the increased CV risk in persons with CAN.
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Affiliation(s)
- Henrik Ø Hjortkjær
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark.
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Jannik Hilsted
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Helle Corinth
- Department of Endocrinology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Ulrik M Mogensen
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Børge G Nordestgaard
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Biochemistry, Herlev and Gentofte Hospital, Copenhagen University Hospital Herlev, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark; Department of Radiology, Rigshospitalet, Copenhagen University Hospital, Denmark
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