ABSTRACT
A neuropatia autonômica cardíaca (NAC) é uma complicação comum do diabetes mellitus (DM) e frequentemente, subdiagnosticada. A NAC está associada ao aumento da mortalidade, cardiovascular e renal, doença renal crônica e maior morbidade em pacientes com DM. Apesar dessas consequências, muitas vezes, a NAC permanece sem diagnóstico por um período prolongado. Isso geralmente porque a doença é assintomática até a fase avançada, bem como pela falta de informações e de estratégias de triagem. Clinicamente NAC se manifesta por distúrbios funcionais ou condições clínicas que envolvem desajuste das atividades reflexas cardiovasculares, tais como taquicardia em repouso, intolerância ao exercício, hipotensão ortostática, instabilidade cardiovascular intraoperatória, disfunção elétrica do coração traduzida por arritmias e isquemia miocárdica silenciosa. Essas alterações comprometem a qualidade de vida e a sobrevida dos pacientes. A NAC, segundo sua evolução, pode ser subdividida em subclínica (fase em que predominam alterações funcionais reversíveis) e clínica (quando as alterações neuronais estruturais estão plenamente estabelecidas). A avaliação da integridade do sistema nervoso autonômico é realizada por meio de exploração da atividade parassimpática, analisando o comportamento da frequência cardíaca (FC) em resposta à respiração profunda, ortostatismo ou manobra de Valsalva. A atividade simpática é explorada por meio de aferição da pressão arterial em resposta a mudança de postura (ortostatismo) e esforço isométrico. A análise da variabilidade da frequência cardíaca (VFC), no domínio do tempo, no domínio da frequência e por métodos gráficos complementam essa avaliação. Neste artigo de revisão, analisamos recentes informações sobre a epidemiologia, manifestações clínicas, diagnóstico, e tratamentos da NAC
Cardiac autonomic neuropathy (CAN) is a common and often-underdiagnosed complication of diabetes mellitus (DM). CAN is associated with increased mortality, cardiovascular disease, chronic kidney disease, and morbidity in patients with DM, but despite these significant consequences CAN often remains undiagnosed for a prolonged period. This is commonly due to the disease being asymptomatic until the later stages, as well as a lack of easily available screening strategies. Clinically, CAN is manifested by functional disorders or clinical conditions that involve maladjustment of cardiovascular reflex activities, such as tachycardia at rest, exercise intolerance, orthostatic hypotension, intraoperative cardiovascular instability, electrical dysfunction of the heart translated by arrhythmias and silent myocardial ischemia. These changes compromise patients' quality of life and survival. CAN, according to its evolution, can be subdivided into subclinical (phase in which reversible functional changes predominate) and clinical (when structural neuronal changes are fully established). The assessment of the integrity of the autonomic nervous system is performed by exploring parasympathetic activity, analyzing the heart rate in response to deep breathing, orthostatism or Valsalva maneuver. Sympathetic activity is explored by measuring blood pressure in response to a change in posture (orthostatism) and isometric effort. The analysis of heart rate variability (HRV), in the time domain, in the frequency domain and by graphic methods, complement this assessment. In this article, we review the latest developments in the epidemiology, pathogenesis, diagnosis, consequences, and treatments of CAN in patients with DM.
ABSTRACT
La neuropatía autonómica cardiovascular en el paciente diabético (NACD) se define como una complicación crónica de la diabetes de tipo microangiopática, que se expresa en disautonomía del sistema cardiovascular. Se realizó un estudio descriptivo transversal cuyo objetivo fue la caracterización epidemiológica y clínica de los pacientes diabéticos tipo 2 con NACD que acudieron a la Unidad de Diabetes del CCR-ASCARDIO de la ciudad de Barquisimeto, estado Lara durante el mes de diciembre del año 2014. La muestra estuvo conformada por 68 individuos diabéticos tipo 2, con una prevalencia de NACD según la prueba de RV del 63,2%, por ortostatismo de 45,6% y por taquicardia sinusal inapropiada de 8,8%. Hubo un predominio del género femenino y un mayor porcentaje de pacientes con NACD no tenían control metabólico de la diabetes y tenían más de 5 años con la enfermedad. En conclusión, se sugiere el diagnóstico precoz de la DM así como la identificación temprana de síntomas que sugieran el desarrollo de disautonomía por deterioro neuropático del sistema cardiovascular en estos pacientes(AU)
Cardiovascular autonomic neuropathy in diabetic patients (CAN) is defined as a chronic complication of diabetes (DM) of the microangiopathic type, which is expressed as dysautonomia of the cardiovascular system. We performed an observational descriptive cross-sectional study to characterize clinically and epidemiologically type 2 diabetic patients with CAN that were attended in December 2014 at the Unidad de Diabetes of CCR-ASCARDIO in Barquisimeto, Lara state. The sample consisted of 68 type 2 diabetic patients with a prevalence of CAN according to the RINES VALCARDI (RV) test of 63.2%, by orthostatism of 45.6% and by the presence of inappropriate sinus tachycardia of 8.8%. In patients with CAN, there was female predominance and a greater percentage of patients had more than five years with diabetes and no metabolic control their disease. In conclusion, it is important to make an early diagnosis of diabetes and clearly identify symptoms that suggest dysautonomia in these patients(AU)
Subject(s)
Humans , Male , Female , Cardiovascular System , Diabetes Mellitus, Type 2/physiopathology , Diabetic Neuropathies , Diabetic Angiopathies , Primary Dysautonomias , Metabolic DiseasesABSTRACT
The influence of β-cell function on cardiovascular autonomic neuropathy (CAN), an important diabetes-related complication, is still unclear. In this study, we aimed to investigate the association between residual β-cell function and CAN in patients newly diagnosed with type 2 diabetes. We enrolled 90 newly-diagnosed type 2 diabetic patients and 37 participants with normal glucose tolerance as controls. The patients were divided into a CAN+ group (diabetic patients with CAN, n = 20) and a CAN- group (diabetic patients without CAN, n = 70) according to the standard Ewing battery of tests. Fasting and postprandial plasma glucose, insulin, and C-peptide were measured. Homeostasis model assessment-beta cells (HOMA-B) and HOMA-insulin resistance (IR) were calculated. The prevalence of CAN in this population was 22.2%. Compared with the CAN- group, the CAN+ group had significantly lower fasting plasma insulin (6.60 ± 4.39 vs 10.45 ± 7.82 μ/L, P = 0.029), fasting C-peptide (0.51 ± 0.20 vs 0.82 ± 0.51 nmol/L, P = 0.004), and HOMA-B (21.44 ± 17.06 vs 44.17 ± 38.49, P = 0.002). Fasting C-peptide was correlated with the Valsalva ratio (r = 0.24, P = 0.043) and the 30:15 test (r = 0.26, P = 0.023). Further analysis showed that fasting C-peptide (OR: 0.041, 95% CI 0.003-0.501, P = 0.012) and HOMA-B (OR: 0.965, 95% CI 0.934-0.996, P = 0.028) were independently associated with cardiovascular autonomic nerve function in this population. The patients with fasting C-peptide values < 0.67 nmol/L were more likely to have CAN than those with C-peptide levels ≥0.67 nmol/L (OR: 6.00, 95% CI 1.815-19.830, P = 0.003). A high prevalence of CAN was found in patients with newly-diagnosed type 2 diabetes. Decreased β-cell function was closely associated with CAN in this population.
Subject(s)
Adult , Female , Humans , Male , Middle Aged , Asian People , Blood Glucose , Diabetes Mellitus, Type 2 , Metabolism , Diabetic Neuropathies , Fasting , Physiology , Glucose , Metabolism , Insulin , Metabolism , Insulin Resistance , Physiology , Insulin-Secreting Cells , MetabolismABSTRACT
Objective To investigate the effect of exercise on the cardiovascular autonomic neuropathy (CAN) in type 2 diabetes mellitus(T2DM) and related risk factors of heart rate recover (HRR).Methods One hundred and five patients with definitely diagnosed T2DM were selected as the research subjects.All patients underwent the oral glucose tolerance test and treadmill exercise test before and after treatment.The related risk factors leading to abnormal HRR were analyzed.Abnormal HRR was divided into the general therapy group (GT) and the intensive therapy group (IT) according to different treatment schemes.The GT group used metformin and diet control,whereas on this basis the IT group accepted the mild enhancement exercise training.The clinical biochemical indicators and HRR change before and after treatment were compared between the two groups.Results Abnormal HRR had significant correlation with FBG,HbA1c,resting heart rate,maximal heart rate and systolic blood pressure(SBP)(P＜0.05).After two-month mild enhancement exercise training,FBG,HbA1c and resting heart rate in the GT group and IT group were significantly decreased compared with those before treatment(P＜0.05),while HRR was significantly increased;compared with those after treatment in the GT group,the FBG,HbA1c levels and resting heart rate in the IT group were significantly decreased,while HRR was significantly increased (P＜0.05).Conclusion FBG,HbA1c and resting heart rate are the important risk factors for abnormal HRR in T2DM patients,mild enhancement exercise training could reduce blood glucose level and increases HRR,thus effectively improve cardiac autonomic neuropathy.
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Objective To investigate the impact of diabetic cardiovascular autonomic neuropathy (DCAN) on heart rate and blood pressure during position change in patients with diabetes mellitus . Methods From January to June 2003 ,54 patients with diabetes mellitus were divided into diabetes mellitus group (n=31) and DCAN group (n= 23) according to the presence or absence of DCAN .22 healthy adults were selected as control group (n= 22 ) . The blood pressure and heart rate were measured continuously by digital arterial blood pressure monitoring system in the process of standing ,squatting and standing up .The changes of blood pressure and heart rate were observed at different time points and posture . Results Compared to NC group ,there were significant increased rangeability of changes in blood pressure [squatting diastolic pressure :(17.9 ± 9.5)vs(24.1 ± 18.1) ,P< 0.05 ;standing systole pressure:(-49.4 ± 20.4)vs(-73.5 ± 21.3)mmHg ,P<0.01 ;standing diastolic pressure :(-32.2 ± 7.1) vs(-43.1 ± 15.8)mmHg ,P<0.05 or P<0.01] and significant decreased rangeability of changes in heart rate [squatting(-21.3 ± 13.0)vs(-6.5 ± 7.8)bpm ,P<0.05 or P<0.01 ;standing(34.6 ± 10.8)vs(11.4 ± 9.8)bpm ,P<0.05 or P<0.01] and remarkable longer recovery time especially in DCAN group (P<0.05 or P<0.01) during standing-squatting-standing test .There was no significant correlation between rangeability of blood pressure changes and heart rate in patients with diabetes . Conclusion There is impaired regulation of blood pressure and heart rate during postural changes in patients with diabetes , especially DCAN .
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Aim: Clinical assessment of the autonomic nervous system in Diabetes mellitus (DM) and its correlation with glycemic control. STUDY DESIGN: Cross sectional study of 50 adult diabetes patients. Materials and Methods: Fifty patients with DM who were on regular treatment with either insulin and/or oral hypoglycemic agents were studied. Cardiovascular autonomic neuropathy (CAN) score was calculated using the clinical test variables. Results: Of the 50 patients 30 had no CAN, 10 had early CAN and 10 had severe CAN. The mean of CAN score increased with duration of diabetes. The mean HbA 1C was 7.73. The mean CAN score was higher in patients who had complication of diabetes as compared to patients without complications. The heart rate variability with respiration was found to be 15.84 ± 7.02/min. The mean valsalva ratio was 1.31 ± 0.23. The mean drop in BP on standing was 7.30 ± 7.24 mmHg. The mean 30:15 ratio was 1.06 ± 0.04. The mean rise in diastolic BP on sustained hand grip was 16.04 ± 4.11 mmHg. Conclusions: The prevalence of autonomic neuropathy in DM as assessed by CAN score was 40%. The CAN score did not correlate with the duration of DM. The HbA 1C had a significant correlation with the severity of autonomic neuropathy. Occurrence of CAN correlated with the presence of peripheral neuropathy but not with the presence of retinopathy or nephropathy. All individual tests in the battery of CAN score were significantly associated with the presence of autonomic neuropathy, except 30:15 ratio.
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Background: Diabetes is an iceberg disease with many complications like cardiovascular disease & diabetic neuropathy. Diabetic autonomic neuropathy is least recognized & most frequent complication. Cardiac autonomic neuropathy is associated with fatal outcome like silent myocardial ischemia & intra-operative liability. With this background we have evaluated the cardiac autonomic neuropathy in diabetic patients using resting blood pressure measurement & isometric hand grip test. Aim:Aim of the study is to analyze the role of handgrip test of & resting blood pressure in diagnosing Cardiac Autonomic Neuropathy. Materials And Methods: A Present cross sectional study was carried out in 50 diabetic patients & 50 controls(age and sex matched) at Sir T. Hospital Bhavnagar. Each subject was evaluated for cardiovascular autonomic neuropathy by isometric hand grip test & resting blood pressure.Diabetic patients were divided in 3 groups according to duration of disease(groupI-< 5 year, II-6 to 10 year, III- > 10 year) to evaluate the impact of duration of disease on autonomic nervous system.We have used student’s T test for comparisons of result between 2 groups. Result:The mean value of resting systolic blood pressure(RSBP) & resting diastolic blood pressure (RDBP)is comparatively higher in diabetic patients compared to controls &the mean value of BP is increasing with duration of diabetes. Isometric hand grip test failure rate was higher in diabetic group than controls. Conclusion: outcome of the study indicates that cardiac autonomic neuropathy is seen in diabetic patients which progresses with duration. Implication of study: isometric hand grip test & resting BP measurement is effective diagnostic tool for cardiac autonomic neuropathy & it also show association with duration of disease.
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BACKGROUND: The aim of this study was to investigate the influences of visceral adiposity on cardiovascular autonomic neuropathy (CAN) in patients with type 2 diabetes mellitus. METHODS: Two hundred eleven patients with type 2 diabetes participated in this study. Anthropometric and metabolic parameters were measured, and the visceral fat area was assessed using computed tomography. CAN was diagnosed using a cardiovascular reflex test. We analyzed the correlation between the visceral fat area and each parameter in this test. RESULTS: The mean age, body mass index (BMI), and duration of diabetes of the study population were 60+/-14 years (mean+/-standard deviation), 25.1+/-4.2 kg/m2, and 12.3+/-8.9 years, respectively. The visceral fat area showed positive correlations with age, BMI, waist circumference, and subcutaneous fat area. There was no statistically significant difference in the cardiovascular reflex test outcome between genders. Univariate linear regression analysis showed that an increased visceral fat area diminished good heart rate response to a Valsalva maneuver (R2=4.9%, P=0.013 in an unadjusted model), but only in women. This statistical association was preserved after adjusting for age and BMI (R2=9.8%, P=0.0072). CONCLUSION: The results of this study suggest that visceral adiposity contributes to an autonomic imbalance to some degree, as demonstrated by the impaired cardiovascular reflex test among women with type 2 diabetes.
Subject(s)
Female , Humans , Adiposity , Body Mass Index , Diabetes Mellitus, Type 2 , Heart Rate , Intra-Abdominal Fat , Linear Models , Obesity , Reflex , Subcutaneous Fat , Valsalva Maneuver , Waist CircumferenceABSTRACT
Objective To investigate the relevant risk factors for cardiovascular autonomic neuropathy (CAN) in diabetic patients. Methods 712 cases of diabetic patients were divided into two groups according to their cardiovascular autonomic function test: one group with CAN (n=160) , and the other without CAN (n=552). Duration of diabetes, profession, body mass index (BMI), blood glucose, lipid profile, glycosylated hemoglobin (HbA1C) and urinary albumin excretion rate (UAER) were measured. Results Duration of diabetes, the levels of fasting plasm glucose (FBG), triglyceride (TG), VLDL-C, APOB, UAER were significantly higher in CAN group than in non-CAN group (P
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Diabetic cardiovascular autonomic neuropathy is the most common and troublesome complication of diabetes mellitus.Diabetic cardiovascular autonomic neuropathy contributes greatly to the morbidity,mortality.Factors in the pathogenesis of these complications are altered metabolism,vascular insufficiency,loss of growth factor trophism,and autoimmune destruction of nerves in a visceral and cutaneous distribution.There are studies in progress that suggest cardiovascular autonomic nerves can be induced to regenerate,and the future for patients with diabetic cardiovascular autonomic neuropathy is brighter.