Word-212K(0) - World Journal of Gastroenterology

|Diabetes and cardiac autonomic neuropathy: Clinical manifestations, |
|cardiovascular consequences, diagnosis and treatment |
|Akif Serhat Balc?o?lu, Haldun Müderriso?lu |
|CITATION |Balc?o?lu AS, Müderriso?lu H. Diabetes and cardiac autonomic |
| |neuropathy: Clinical manifestations, cardiovascular |
| |consequences, diagnosis and treatment. World J Diabetes 2015; |
| |6(1): 80-91 |
|URL |http://www.wjgnet.com/1948-9358/full/v6/i1/80.htm |
|DOI |http://dx.doi.org/10.4239/wjd.v6.i1.80 |
|OPEN ACCESS |Articles published by this Open-Access journal are distributed |
| |under the terms of the Creative Commons Attribution |
| |Non-commercial License, which permits use, distribution, and |
| |reproduction in any medium, provided the original work is |
| |properly cited, the use is non commercial and is otherwise in |
| |compliance with the license. |
|CORE TIP |Although very frequent, cardiac autonomic neuropathy (CAN) is |
| |one of the most commonly overlooked complication of diabetes. |
| |Higher incidence of cardiovascular events is encountered with |
| |CAN due to its relation with silent myocardial ischemia, |
| |arrhythmias, intraoperative cardiovascular instability, |
| |orthostatic hypotension and cardiomyopathy. Diabetic patients |
| |should be screened for CAN due to the possibility of reversal |
| |of cardiovascular denervation in the early stages of the |
| |disease. Cardiovascular reflex tests and Holter-derived time- |
| |and frequency-domain measurements are frequently used for the |
| |diagnosis. Therapeutic approaches are promising and may hinder |
| |or reverse the progression of the disease when initiated during|
| |the early stages. |
|KEY WORDS |Diabetes mellitus; Autonomic neuropathy; Heart rate |
| |variability; Cardiac; Cardiovascular reflex tests |
|COPYRIGHT |© The Author(s) 2015. Published by Baishideng Publishing Group |
| |Inc. All rights reserved. |
|COPYRIGHT |Order reprints or request permissions: bpgoffice@wjgnet.com |
|LICENSE | |
|NAME OF |World Journal of Diabetes |
|JOURNAL | |
|ISSN |1948-9358 ( online) |
|PUBLISHER |Published by Baishideng Publishing Group Inc, 8226 Regency |
| |Drive, Pleasanton, CA 94588, USA |
|WEBSITE |http://www.wjgnet.com | ESPS Manuscript NO: 13432
Columns: REVIEW Diabetes and cardiac autonomic neuropathy: Clinical manifestations,
cardiovascular consequences, diagnosis and treatment Akif Serhat Balc?o?lu, Haldun Müderriso?lu Akif Serhat Balc?o?lu, Medical and Research Center of Alanya, Department of
Cardiology, Ba?kent University, 07400 Alanya, Antalya, Turkey
Haldun Müderriso?lu, Faculty of Medicine, Department of Cardiology, Ba?kent
University, 06490 Ankara, Turkey
Author contributions: Balc?o?lu AS performed the literature search and
wrote the paper; Müderriso?lu H provided expert opinion and reviewed the
article.
Conflict-of-interest: The authors confirm that the manuscript has no
conflict of interest.
Open-Access: This article is an open-access article which was selected by
an in-house editor and fully peer-reviewed by external reviewers. It is
distributed in accordance with the Creative Commons Attribution Non
Commercial (CC BY-NC 4.0) license, which permits others to distribute,
remix, adapt, build upon this work non-commercially, and license their
derivative works on different terms, provided the original work is properly
cited and the use is non-commercial. See:
http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Akif Serhat Balc?o?lu, MD, Medical and Research Center
of Alanya, Department of Cardiology, Ba?kent University, Saray Mahallesi,
Yunus Emre Caddesi, No: 1, 07400 Alanya, Antalya, Turkey.
serhatbalcioglu@gmail.com
Telephone: +90-242-5102525
Fax: +90-242-5115563
Received: August 22, 2014
Peer-review started: August 23, 2014
First decision: September 19, 2014
Revised: November 16, 2014
Accepted: November 27, 2014
Article in press: December 1, 2014
Published online: February 15, 2015
Abstract
Cardiac autonomic neuropathy (CAN) is a frequent chronic complication of
diabetes mellitus with potentially life-threatening outcomes. CAN is caused
by the impairment of the autonomic nerve fibers regulating heart rate,
cardiac output, myocardial contractility, cardiac electrophysiology and
blood vessel constriction and dilatation. It causes a wide range of cardiac
disorders, including resting tachycardia, arrhythmias, intraoperative
cardiovascular instability, asymptomatic myocardial ischemia and infarction
and increased rate of mortality after myocardial infarction. Etiological
factors associated with autonomic neuropathy include insufficient glycemic
control, a longer period since the onset of diabetes, increased age, female
sex and greater body mass index. The most commonly used methods for the
diagnosis of CAN are based upon the assessment of heart rate variability
(the physiological variation in the time interval between heartbeats), as
it is one of the first findings in both clinically asymptomatic and
symptomatic patients. Clinical symptoms associated with CAN generally occur
late in the disease process and include early fatigue and exhaustion during
exercise, orthostatic hypotension, dizziness, presyncope and syncope.
Treatment is based on early diagnosis, life style changes, optimization of
glycemic control and management of cardiovascular risk factors. Medical
therapies, including aldose reductase inhibitors, angiotensin-converting
enzyme inhibitors, prostoglandin analogs and alpha-lipoic acid, have been
found to be effective in randomized controlled trials. The following
article includes the epidemiology, clinical findings and cardiovascular
consequences, diagnosis, and approaches to prevention and treatment of CAN. Key words: Diabetes mellitus; Autonomic neuropathy; Heart rate variability;
Cardiac; Cardiovascular reflex tests © The Author(s) 2015. Published by Baishideng Publishing Group Inc. All
rights reserved. Core tip: Although very frequent, cardiac autonomic neuropathy (CAN) is one
of the most commonly overlooked complication of diabetes. Higher incidence
of cardiovascular events is encountered with CAN due to its relation with
silent myocardial ischemia, arrhythmias, intraoperative cardiovascular
instability, orthostatic hypotension and cardiomyopathy. Diabetic patients
should be screened for CAN due to the possibility of reversal of
cardiovascular denervation in the early stages of the disease.
Cardiovascular reflex tests and Holter-derived time- and frequency-domain
measurements are frequently used for the diagnosis. Therapeutic approaches
are promising and may hinder or reverse the progression of the disease when
initiated during the early stages.
Balc?o?lu AS, Müderriso?lu H. Diabetes and cardiac autonomic neuropathy:
Clinical manifestations, cardiovascular consequences, diagnosis and
treatment. World J Diabetes 2015; 6(1): 80-91 Available from: URL:
http://www.wjgnet.com/1948-9358/full/v6/i1/80.htm DOI:
http://dx.doi.org/10.4239/wjd.v6.i1.80
INTRODUCTION
Cardiac autonomic neuropathy (CAN), a type of gene-ralized symmetric
polyneuropathy, is the most examined and clinically significant diabetic
autonomic neuropathy[1]. The autonomic nervous system has 2 major
components: the parasympathetic and the sympathetic nervous systems. These
may operate independently of each other or interact cooperatively to
control heart rate, cardiac output, myocardial contractility, cardiac
electrophysiology, and the constriction and dilatation of blood vessels[2].
CAN is caused by damage to the autonomic nerve fibers that innervate the
heart and blood vessels and leads to abnormalities in cardiovascular
dynamics[2]. The earliest finding of CAN, even at the subclinical stage, is
a decrease in heart rate variability (HRV)[3]. EPIDEMIOLOGY
Diabetes is estimated to affect approximately 350 million people
globally[4]. Diabetic neuropathies, including CAN, are frequent chronic
complications of type 1 and 2 diabetes that influence quality of life and
have potentially fatal outcomes[2]. Prevalence rates between 1.6% to 90%
have been reported, varying according to the diagnostic methods used,
population studied and disease stage[1]. The Diabetes Control and
Complications Trial (DCCT) showed abnormal HRV values of 1.65%, 6.2% and
12.2% in patients with diabetes for a duration of less than 5 years, 5 to 9
years and more than 9 years, respectively[5]. A study including 1171
patients with both type of diabetes mellitus reported impaired HRV tests in
25.3% of type 1 and 34.3% of type 2 patients[6]. The different meth