CARDIAC AUTONOMIC NEUROPATHY IN DIABETES

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CARDIAC AUTONOMIC NEUROPATHY IN DIABETES

            Caradiac autonomic neuropathy assesses autonomic nervous system that innervates circulatory system (cardiovascular reflex). Caradiac autonomic neuropathy induces severe postural hypotension and silent MI and lead to sudden cardiac death.
  • Sudden syncope
  • Light headedness
  • Transient visual loss
  • Pallor
  • Extreme weakness
  • Diaphorism
  • Post prandial hypotension
  • Reduced exercise tolerance
  • Ischemic pattern on ECG
            Neuropathy of sympathetic afferent nerve fibers responsible for painless infarction on exercise diabetic patient less able to increase heart rate, blood pressure and cardiac output.
Heart Rate
            Parasympathetic fibres affected early i.e. damage tests are
  1. Heart Rate response to deep breathing: continuing ECG taken in deep inspiration and expiration (6 breath/min) max and minimum RR calculated,  converted to beats/min normal 15 beats/min. <10 is abnormal.
  2. Immediate heart rate response to standing
  3. Valsalva ratio
Blood Pressure
            Cardiac sympathetic damage
  1. BP response to sudden standing (portural hypotension) normal fall in blood pressure <10mmHg, <30 abnormal, 11-29 bordernline.
  2. BP response to sustain handgrip max diastolic blood pressure, resting DBP normal >16 mmHg, if <10mm Hg abnormal and 11-15 borderline.
  3. BP response to cold pressure test rinse in ice cold water normal DBP increases >8mm Hg
Worsen CAN
            ACE, a blockers, methyl dopa, clonidine, phenothiazine, barbiturate, tricyclic and antidepresents.
CAN Management
            Strict glycemic control, a lipoic acid (antioxidant), aldose reduction inhibitor and L-carnitine.
CONCLUSION:
            CAN decisive tests;
  1. Valsalva ratio <1.1
  2. Portural hypotension >30mm Hg fall (SBP)
  3. Failure of DBP to rise in sustained handgrip <10mmHg
  4. Failure of DBP to rise on cold pressure <8mm rise
REFERENCE:

            RSSDI Text Book of Diabetes Mellitus 

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