Diabetes Metab J.  2019 Feb;43(1):3-30. 10.4093/dmj.2018.0259.

Update on the Impact, Diagnosis and Management of Cardiovascular Autonomic Neuropathy in Diabetes: What Is Defined, What Is New, and What Is Unmet

Affiliations
  • 1Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy. vispa@mclink.it

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.

Keyword

Autonomic nervous system; Cardiovascular system; Diabetic neuropathies; Diagnosis; Epidemiology; Glucagon-like peptide-1 receptor; Hypotension, orthostatic; Prognosis; Sodium-glucose transporter 2 inhibitors; Therapeutics

MeSH Terms

Autonomic Nervous System
Biomarkers
Cardiovascular System
Diabetes Mellitus, Type 1
Diabetes Mellitus, Type 2
Diabetic Neuropathies
Diagnosis*
Epidemiology
Glucagon-Like Peptide-1 Receptor
Heart Rate
Hypertension
Hypotension, Orthostatic
Inflammation
Life Style
Mass Screening
Mortality
Obesity
Oxidative Stress
Prognosis
Reflex
Risk Factors
Tachycardia
Vitamin B 12
Biomarkers
Glucagon-Like Peptide-1 Receptor
Vitamin B 12
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