A Study of Cardiac Autonomic Neuropathy in Patients with Type 2 Diabetes Mellitus: A Northeast India Experience

Knowledge, attitude, and practice toward weight management among diabetic patients in Qidong City, Jiangsu Province

BACKGROUND

Weight management is an effective prevention and treatment strategy for diabetes mellitus. This study aimed to assess the knowledge, attitude, and practice (KAP) of diabetic patients towards weight management.

METHODS

Diabetic patients treated at Qidong City, Jiangsu Province, between January 2023 and June 2023 were included in this cross-sectional study. A self-designed questionnaire was used to collect their demographic characteristics and KAP toward weight management. Structural equation modeling (SEM) was employed to examine the inter-relationships among KAP scores.

RESULTS

Among a total of 503 valid questionnaires that were collected, 55.07% were filled out by men and 54.67% by those aged < 60 years. The mean scores for knowledge, attitude, and practice were 8.03 ± 3.525 (possible range: 0-13), 31.88 ± 3.524 (possible range: 10-50), and 22.24 ± 3.318 (possible range: 9-45), respectively. Pearson's correlation analysis revealed the knowledge was positively associated with attitude (r = 0.295, P < 0.001) and practice (r = 0.131, P < 0.001), and attitude was positively associated with practice (r = 0.140, P = 0.002). SEM demonstrated positive associations between knowledge and attitude (β = 0.28, P < 0.001), and attitude and practice (β = 0.09, P = 0.019). Moreover, older age was negatively associated with knowledge (β=-0.04, P = 0.001), while higher education (β = 1.220, P < 0.001), increased monthly income (β = 0.779, P < 0.001), diagnosis of fatty liver (β = 1.03, P = 0.002), and screening for excess visceral fat (β = 1.11, P = 0.002) were positively associated with knowledge.

CONCLUSION

Diabetic patients showed moderate knowledge, neutral attitudes, and inappropriate practices toward weight management. Knowledge was positively associated with attitude and practice. These findings provided valuable directions for healthcare interventions targeting improved KAP status of weight management among diabetic patients.

Cardiac Autonomic Neuropathy in Newly Diagnosed Patients With Type 2 Diabetes Mellitus

INTRODUCTION

Cardiac autonomic neuropathy (CAN) is a debilitating complication in diabetes mellitus, leading to life-threatening arrhythmias and various impairments. Its prevalence varies widely, and early detection and management are crucial. This study investigates the prevalence of CAN in newly diagnosed type 2 diabetes mellitus patients in Central India, comparing them to a control group.

METHODOLOGY

This case-control study included 35 newly diagnosed type 2 diabetes mellitus patients and 35 age-matched healthy controls from the general population. Cardiac autonomic function testing (AFT) was done by heart rate variability (HRV), the deep breathing test (DBT), the cold pressor test (CPT), and the lying-to-standing test (LST). Parameters were recorded and analyzed using statistical tests.

RESULTS

Patients with type 2 diabetes mellitus had significantly higher weight, BMI, fasting blood sugar, post-prandial blood sugar, urine albumin-creatinine ratios, and systolic and diastolic blood pressure than controls. Abnormalities in HRV and E: I ratio during the DBT and CPT were more prevalent in these patients. Parasympathetic dysfunction (delta HR) and a lower E: I ratio were also significantly high in this group. Also, LST results suggested a greater likelihood of orthostatic symptoms in the patients' group.

CONCLUSION

This study highlights the importance of AFT in diagnosing early CAN in newly diagnosed patients. Early diagnosis and management of diabetic CAN are essential to prevent complications.

Prevalence of cardiac autonomic neuropathy in patients with type 2 diabetes mellitus

Introduction

Cardiac autonomic neuropathy (CAN) is one of the microvascular complications of diabetes mellitus, which is due to the involvement of autonomic nerve fibers innervating the heart and blood vessels. CAN was found to have a greater degree of morbidity and mortality than their non-CAN counterparts as it is underdiagnosed. Hence, this study aims to determine the prevalence and severity of CAN in type 2 diabetics in the South Indian setting.

Materials and Methods

Forty-two patients with type 2 diabetes mellitus were enrolled in the study. Patients underwent tests for CAN, with the severity of CAN estimated as a CAN score, which was the sum of the scores of the four cardiovascular autonomic function tests.

Results

Out of the 42 patients, a total of 36 patients (85.7%) were diagnosed with CAN. Among those with CAN, 24 patients had early CAN (57.1%), and 12 were diagnosed with definite CAN (28.6%). Patients with any form of CAN (early and definite CAN) had higher HbA1c and mean glucose values than those without CAN. CAN was also found to be more severe among older patients with diabetes.

Conclusion

In the present study, we found that more than 50% of the study population had early CAN and around 28.6% patients had definite CAN indicating higher prevalence of CAN in our population. Also, there was a positive correlation between the severity of CAN and the age of the patients. This study highlights the importance of understanding the importance of screening the diabetic patients for CAN to prevent adverse cardiovascular events.

Assessment of Triglyceride Glucose Index in Type 2 Diabetes Mellitus Patients With and Without Cardiac Autonomic Neuropathy

Background Cardiac autonomic neuropathy (CAN) is a major complication of type 2 diabetes mellitus (T2DM). Hyperglycaemia and hypertriglyceridemia are known risk factors in the development of CAN with T2DM. The triglyceride glucose (TyG) index is calculated using both the fasting blood glucose (FBG) and fasting triglyceride levels (FTG). There is a paucity of literature revealing a direct relationship between the TyG index and CAN in T2DM patients of the south Indian population. Objective To assess the TyG index levels in T2DM with and without CAN. Methods A cross-sectional study was performed, involving 100 T2DM patients (58 males and 42 females) aged between 30 and 60 years, who attended medicine OPD, Sri Venkateswaraa Medical College, Hospital and Research Centre (SVMCH & RC) during the study period. Age, duration of illness, height, weight, waist circumference (WC), hip circumference (HC), body mass index (BMI), systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured. Glycated hemoglobin (HbA1C) and lipid profile values were taken from patients' recent medical records. Ewing autonomic function tests were used to diagnose CAN, which included heart rate response to standing, heart rate response to deep breathing, heart rate response to Valsalva maneuver, blood pressure response to standing and blood pressure response to isometric handgrip. FBG and FTG were measured and the TyG index was calculated from these parameters. Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Version 20.0, Armonk, NY) was used for the statistical analysis and a 'P' value < 0.05 was considered statistically significant. Results In our study, out of 100 T2DM patients, 42 patients were diagnosed with CAN. The mean levels of TyG Index, HbA1C, FBG, FTG, BMI and WC were significantly (p<0.05) higher in T2DM patients with CAN when compared to T2DM without CAN. We couldn't find any significant difference (p<0.05) in age, duration of illness, blood pressure and lipid profile parameters between the groups. Conclusion We found that abdominal obesity, hyperglycemia, and hypertriglyceridemia are the risk factors for developing CAN in T2DM patients. Our study results also showed that the TyG index can be used to predict CAN in T2DM patients.

Association between Polypharmacy and Cardiovascular Autonomic Function among Elderly Patients in an Urban Municipality Area of Kolkata, India: A Record-Based Cross-Sectional Study

We assessed the association between polypharmacy and cardiovascular autonomic function among community-dwelling elderly patients having chronic diseases. Three hundred and twenty-one patients from an urban municipality area of Kolkata, India were studied in August 2022. The anticholinergic burden and cardiac autonomic function (Valsalva ratio, orthostatic hypotension, change in diastolic blood pressure after an isometric exercise, and heart rate variability during expiration and inspiration) were evaluated. Binary logistic regression analysis was performed to find out the association of polypharmacy and total anticholinergic burden with cardiac autonomic neuropathy. A total of 305 patients (age, 68.9 ± 3.4; 65.9% male) were included. Of these patients, 81 (26.6%) were on polypharmacy. Out of these 81 patients, 42 patients were on ninety-eight potential inappropriate medications. The anticholinergic burden and the proportion of patients with cardiac autonomic neuropathy were significantly higher among patients who were on polypharmacy than those who were not (8.1 ± 2.3 vs. 2.3 ± 0.9; p = 0.03 and 56.8% vs. 44.6%; p = 0.01). The presence of polypharmacy and a total anticholinergic burden of > 3 was significantly associated with cardiac autonomic neuropathy (aOR, 2.66; 95% CI, 0.91−3.98 and aOR, 2.51; 95% CI, 0.99−3.52, respectively). Thus, polypharmacy was significantly associated with cardiac autonomic neuropathy among community-dwelling elderly patients.

Age and Disease Duration Independent Cardiac Autonomic Neuropathy in Patients with Diabetic Foot Complications: Case-Control Study

INTRODUCTION

Cardiac autonomic neuropathy (CAN) in people with diabetes is associated with high mortality. We aimed to study age and disease duration, independent prevalence of CAN in people with diabetic foot complications.

METHODS

530 patients with diabetes were screened to undergo CAN assessment (automated CANS-analyser). CAN was defined as "early", "definite," or "severe" according to the Toronto consensus. History pertaining to autonomic symptoms, prior cardiovascular events (CVE), and assessment for peripheral neuropathy was done. Participants were grouped into those with diabetic foot complication (group A, n = 82) [Charcot foot (n = 42), diabetic foot ulcer (n = 40)]; with DPN without foot complications (group B, n = 82); and without DPN or foot complications (group C, n = 82).

RESULTS

Symptoms of autonomic dysfunction were prominent in people with foot complications than the other groups. Resting heart rate was significantly greater in those with foot complications [99.89 ± 26.71 (group A) vs. 86.99 ± 22.24 (group B) vs. 88.32 ± 17.08 (group C); P = 0.001]. The prevalence of CAN was 75.6% in group A (51.2% early, 12.2% definite, 12.2% severe), 57.2% in group B (45.1% early, 12.2% severe) and 58.5% in group C (43.9% early, 1.2% definite, 13.4% severe) (P = 0.002). Patients with foot complications were more likely to have CAN (75.6% vs. 57.9%, P < 0.001). Charcot foot had higher prevalence of CAN (78.6%) as compared with those with DFU (72.5%) or without DFU or DPN (57.9%), P < 0.001.

CONCLUSION

CAN is present in more than two-third of patients with diabetes and foot complications with highest prevalence in Charcot neuroarthropathy.

Noninvasive exploration of Cardiac Autonomic Neuropathy by heart rate and blood pressure variability analysis in Type 2 Diabetic patients

Objectives

To determine the prevalence of asymptomatic cardiac autonomic neuropathy and its association with risk factors among patients with Type-2 diabetes mellitus (T2DM).

Methods

The present case-control study was conducted at Department of Medicine, Civil Hospital, Dow University of Health Sciences (DUHS), Karachi, Pakistan during the period September` 2016 to May` 2017. After taking informed consent, subjects from both genders, 72 healthy controls and 72 clinically diagnosed T2DM diabetic patients, age between 30-65 years were selected by non-probability sampling technique. After taking medical history and demographics, Cardiac Autonomic Neuropathy (CAN) was identified by using Ewing`s cardiac autonomic reflex tests (CARTs) and association of risk factors was also investigated.

Results

Severe CAN was identified in 13.9% of T2DM patients while in none of the healthy controls. HR response to deep breathing test was most sensitive (sensitivity= 90%) among all tests. The most common symptoms were Numbness (75.9%) and constipation (69%), resting heart rate and diabetes duration was significantly associated with DCAN.

Conclusions

CAN was highly prevalent in diabetic population that may lead to nephropathy and retinopathy in future. It is highly recommended to use sensitive and simple CARTs in clinics for early detection and early treatment of CAN.

Correlation of staging and risk factors with cardiovascular autonomic neuropathy in patients with type II diabetes mellitus

The impairment of cardiovascular autonomic control among the underdiagnosed complication of diabetes mellitus (DM) with a high prevalence rate of up to 60% in type 2 DM (T2DM). Cardiac autonomic neuropathy (CAN) is an independent risk factor for cardiovascular mortality, arrhythmia, silent ischemia, any major cardiovascular event, and heart failure. We aimed to evaluate cardiovascular autonomic activity by different physiological maneuvers, study risk factors for diabetic CAN including age, gender, duration of diabetes, body mass index (BMI), and glycemic control, and correlate CAN stage with risk factors. One hundred and forty-two T2DM patients consisted of 62 males and 80 females and 100 volunteers as a control sample. Cardiac autonomic functions were assessed by Ewing's tests. Glycated hemoglobin (HbA1c), body weight, height, body mass index (BMI), and waist-hip ratio (WHR) were also measured. Cardiovascular autonomic functions and Ewing scores were significantly different in people with diabetes when compared with control healthy subjects. Ewings test values and Ewing scores were significantly different between diabetics with and without CAN and within patients with different CAN staging. People with diabetes with CAN have a significantly longer duration of disease when compared to those without CAN. A strong association has been found between CAN severity and patient age, duration of disease, HbA1c severity, and the WHR (P < 0.001) but not with BMI. The duration of disease and HbA1c level appear to be associated with the development of CAN (P = 0.001 and P = 0.008, respectively). The poorer glycemic control and the longer the duration of the disease, the higher the prevalence of CAN in T2DM. Age, duration of disease, WHR, and HbA1c are well correlated with the severity of CAN. Parasympathetic impairment is more sensitive to the detection of autonomic dysfunctions than do sympathetic impairment.

Assessment of sudomotor function in hypertensive with/without type-2 diabetes patients using SUDOSCAN: An electrophysiological study

Objective

Electrochemical skin conductance (ESC) test is a simple and non-invasive screening test can detect dysfunction of the peripheral sudomotor, and indirectly estimates the function of cardiac autonomic nerves. This study aimed to assess the ESC values in hypertensive patients with/without type-2 diabetes by using SUDOSCAN technology. Moreover, this study evaluated the role of cardiometabolic risk factors on the results of ESC test.

Methods

This cross-sectional study was carried on three groups of participants, including healthy subjects (Group I, n = 49), hypertensive without type-2 diabetes (Group II, n = 75) patients, and hypertensive with type-2 diabetes (Group III, n = 76) patients. Body mass index (BMI), blood pressure (systolic, diastolic and pulse pressure index), fasting serum glucose, and lipid profile were determined. ESC test as a measurement sudomotor function was determined by applying a small direct current at low voltage to hands and feet sensor plates through SUDOSCAN device.

Results

ESC values of the peripheral sudomotor nerves in the Group II and III patients were significantly lower than the corresponding values of Group I. SUDOSCAN results of Group II and III. Significant discriminators of cardiac autonomic neuropathy (≥30 score) that determined by the area under the curve (AUC) with 95% confidence interval (95% C.I.) were, duration of the disease, BMI, and mean blood pressure in Group II, while the duration of the disease and the BMI were significant discriminators in Group III.

Conclusions

SUDOSCAN is a simple, useful device, which can detect the impairment of peripheral autonomic small nerve fibers and the risk of cardiac autonomic neuropathy in hypertension. Moreover, the duration of the disease and the associated cardiometabolic risk factors are important predictors of significant SUDOSCAN findings.

Significance

ESC test is useful in detecting subclinical neuropathy in hypertensive patients as well as in type 2 diabetes.

Assessment of sudomotor function in hypertensive with/without type-2 diabetes patients using SUDOSCAN: An electrophysiological study

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SUDOSCAN is a simple non-invasive device that can assess the sudomotor nerves.

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Hypertensive patients have sub-clinical impairment of peripheral and autonomic nerve fibers function.

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Cardio-metabolic risk factors are important discriminators of abnormal SUDOSCAN data.

Objective

Electrochemical skin conductance (ESC) test is a simple and non-invasive screening test can detect dysfunction of the peripheral sudomotor, and indirectly estimates the function of cardiac autonomic nerves. This study aimed to assess the ESC values in hypertensive patients with/without type-2 diabetes by using SUDOSCAN technology. Moreover, this study evaluated the role of cardiometabolic risk factors on the results of ESC test.

Methods

This cross-sectional study was carried on three groups of participants, including healthy subjects (Group I, n = 49), hypertensive without type-2 diabetes (Group II, n = 75) patients, and hypertensive with type-2 diabetes (Group III, n = 76) patients. Body mass index (BMI), blood pressure (systolic, diastolic and pulse pressure index), fasting serum glucose, and lipid profile were determined. ESC test as a measurement sudomotor function was determined by applying a small direct current at low voltage to hands and feet sensor plates through SUDOSCAN device.

Results

ESC values of the peripheral sudomotor nerves in the Group II and III patients were significantly lower than the corresponding values of Group I. SUDOSCAN results of Group II and III. Significant discriminators of cardiac autonomic neuropathy (≥30 score) that determined by the area under the curve (AUC) with 95% confidence interval (95% C.I.) were, duration of the disease, BMI, and mean blood pressure in Group II, while the duration of the disease and the BMI were significant discriminators in Group III.

Conclusions

SUDOSCAN is a simple, useful device, which can detect the impairment of peripheral autonomic small nerve fibers and the risk of cardiac autonomic neuropathy in hypertension. Moreover, the duration of the disease and the associated cardiometabolic risk factors are important predictors of significant SUDOSCAN findings.

Significance

ESC test is useful in detecting subclinical neuropathy in hypertensive patients as well as in type 2 diabetes.