RR‐variation: The autonomic test of choice in diabetes

Genovely, H.; Pfeifer, Michael

doi:10.1002/dmr.5610040305

Cited by 107 publications

(45 citation statements)

References 53 publications

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“…This finding has been confirmed by other investigators 10 and is in agreement with what has been observed in diabetic patients, in which diuretic treatment did not interfere with cardiovascular test results. 42 The most intriguing result of the present study was the association between AD (mainly vagal) and features of the hyperdynamic circulatory syndrome. In fact, although patients without AD already showed cardiovascular abnormalities, those with AD presented a further worsening of these disturbances, despite the fact that the degree of liver failure and anemia, which can worsen the hyperdynamic circulatory syndrome, 43 did not differ between the groups.…”

Section: Discussionmentioning

confidence: 62%

Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites

et al. 1999

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Patients with advanced cirrhosis frequently show hemodynamic abnormalities. Autonomic dysfunction (AD) is also common and, owing to the importance of autonomic function in cardiovascular homeostasis, it may be involved in the pathogenesis of the hyperdynamic circulation. We, therefore, evaluated the hemodynamic status and autonomic function in 30 patients with cirrhosis, most of them with an advanced stage of the disease. Autonomic function was assessed with 7 cardiovascular tests exploring the vagal or sympathetic function. Each test was scored from 1 to 3 (normal, borderline, altered). Cardiac index (CI) was measured by an echocardiogram. Twenty-four (80%) patients showed an AD, this being definite in 14 (47%) patients. A vagal dysfunction (VD) was found in 19 patients (63%), this being definite in 11 patients (37%), and a sympathetic dysfunction (SD) in 7 patients (definite in 3 [10%] patients). The patients with AD showed a faster heart rate (P ‫؍‬ .021), lower indicized peripheral vascular resistance (P ‫؍‬ .013), and increased CI (P ‫؍‬ .004) than patients without AD whereas mean arterial pressure did not differ. Similar results were seen by grouping patients according to the VD. AD score was directly correlated with heart rate (r ‫؍‬ 0.53; P ‫؍‬ .002) and CI (r ‫؍‬ 0.45; P ‫؍‬ .016), and inversely correlated with peripheral vascular resistance (r ‫؍‬ 0.46; P ‫؍‬ .013). Even closer correlations were found with vagal score. AD (mainly VD) may be involved in the pathogenesis of the hyperdynamic circulatory syndrome of patients with advanced cirrhosis. (HEPATOLOGY 1999;30:1387-1392.)Hyperdynamic circulation is a common and long-recognized feature of patients with advanced cirrhosis, 1 consisting of elevated cardiac rate and output and reduced peripheral vascular resistance, so that arterial pressure is tendentially or frankly reduced. The clinical importance of this disorder was shown by subsequent studies, showing that the alterations of systemic hemodynamics, renal function, and vasoactive systems are prognostic indicators even more accurate than the tests exploring liver function. 2 The setting of the hyperdynamic circulatory syndrome is the pathogenetic background of complications such as renal sodium and water retention and hepatorenal syndrome. 3 Splanchnic blood pooling, opening of portal-systemic collaterals, and arterial vasodilation, as well as a compensatory increase in blood volume, are the causative events of the hyperdynamic circulatory syndrome. 4,5 The pathogenesis of arterial vasodilation is still debated. It has been proposed that an overproduction of a variety of vasorelaxant agents, such as histamine, adenosine, gut-derived peptides and endothelial cell-derived vasodilators, and bile acid retention reduce the responsiveness of the vascular bed to endogenous vasoconstrictor stimuli. 4,6 The autonomic nervous system plays a central role in modulating cardiac performance and vasomotor activity. The presence of an autonomic dysfunction (AD) in cirrhosis has been clearly shown through different...

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Section: Discussionmentioning

confidence: 62%

Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites

et al. 1999

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“…In addition to patients with IDDM without classical diabetic autonomic neuropathy, nondiabetic subjects and patients with classical diabetic autonomic neuropathy were studied. The latter were selected on the basis of both reduced heart rate variation during deep breathing, a well-established indicator ofautonomic neuropathy (29) Patients with IDDM exhibited higher symptom scores than nondiabetic subjects at the lower plasma glucose concentrations. This observation confirms previous evidence that glycemic thresholds for symptoms are reduced (i.e., at higher plasma glucose concentrations) in patients with poorly or moderately controlled IDDM ( 13, 17, 18).…”

Section: Discussionmentioning

confidence: 99%

Hypoglycemia-associated autonomic failure in insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reduces autonomic responses to, symptoms of, and defense against subsequent hypoglycemia.

Dagogo‐Jack¹,

Craft²,

Cryer³

1993

J. Clin. Invest.

419

166

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IntroductionWe hypothesize that in patients with insulin-dependent diabetes mellitus (IDDM), recent antecedent iatrogenic hypoglycemia is a major cause of hypoglycemia-associated autonomic failure, a disorder distinct from classical diabetic autonomic neuropathy (CDAN), and that hypoglycemia-associated autonomic failure, by reducing both symptoms of and defense against developing hypoglycemia, results in recurrent iatrogenic hypoglycemia, thus creating a vicious cycle. We used the hyperinsulinemic ( 12.0 pmol * kg-l * min' ) stepped hypoglycemic clamp technique to assess autonomic and symptomatic responses to hypoglycemia and the insulin infusion test (4.0 pmol * kg-' * min-') to assess defense against hypoglycemia on mornings before and after clamped afternoon hypoglycemia (a 2.8 mmol/liter) and hyperglycemia (-11 ( 13,(15)(16)(17). These syndromes have been reviewed ( 1, 4, 5). Administration of a 3-adrenergic antagonist may also be a risk factor in this category (18). The prevention or correction of hypoglycemia is normally the result of both dissipation of insulin and activation of glucose counterregulatory systems. Whereas insulin is the dominant glucose-lowering factor, there are redundant glucose-raising (counterregulatory) factors, and there is a hierarchy among the glucoregulatory factors ( 1, 19). Among the several counterregulatory factors, glucagon and epinephrine (particularly in the absence of glucagon) play key roles. The secretion of glucagon and epinephrine, as well as insulin, is abnormal in IDDM. Absolute insulin deficiency is the proximate cause of IDDM. The hormone must be replaced, currently by subcutaneous injection or infusion, but the appearance of insulin in the circulation is unregulated and does not fall as plasma glucose levels decline. Selectively deficient pancreatic a-cell glucagon responses to decrements in plasma glucose are the rule in established IDDM (20)(21)(22). Thus, patients with IDDM, in contrast to nondiabetic persons, are largely dependent upon epinephrine to prevent or correct hypoglycemia (23). Selectively deficient adrenomedullary epinephrine responses to decrements in plasma glucose also develop in the majority of patients with relatively longstanding IDDM (21,24). This is a critical abnormality in the setting of intermittent hyperinsulinemia and deficient glucagon responses. The superimposition of epinephrine deficiency results in a 25-fold or greater increase in the frequency of severe iatrogenic hypoglycemia, at least dur-1. Abbreviations used in this paper: CDAN, classical diabetic autonomic neuropathy; IDDM, insulin-dependent diabetes mellitus.Hypoglycemia-associated Autonomic Failure J. Clin. Invest.

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“…In addition, vector analysis of the instantaneous heart rate was performed, and mean circular resultant was determined. This alternative index of heart rate variability minimizes error introduced by variation in intrinsic heart rate or ectopic cardiac beats (10). Heart rate response to the Valsalva maneuver.…”

Section: Rd Hoeldtke and Associatesmentioning

confidence: 99%

Redistribution of Sudomotor Responses Is an Early Sign of Sympathetic Dysfunction in Type 1 Diabetes

et al. 2001

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Patients with diabetic neuropathy typically have decreased sweating in the feet but excessive sweating in the upper body. Previous studies of sudomotor function in diabetes have included patients with longstanding disease. The present study was designed to test for the early presence of sudomotor dysfunction and to characterize its relation to glycemic control and other aspects of peripheral nerve function. A total of 37 patients (10 males, 27 females) enrolled in a longitudinal study, in which autonomic function was evaluated annually for 3 years. Patients enrolled 2-22 months after the diagnosis of type 1 diabetes. Forty-one ageand sex-matched healthy control subjects were also studied. Sweat production in response to acetylcholine stimulation was dramatically increased in the forearm at the time of the first evaluation (1.67 ± 0.24 µl/cm 2 in the diabetic patients vs. 1.04 ± 0.14 µl/cm 2 in the control subjects, P < 0.05). Likewise, the ratio of sweating in the forearm to sweating below the waist was higher in the diabetic patients (0.553 ± 0.07 µl/cm 2 ) than in the control subjects (0.385 ± 0.04 µl/cm 2 , P < 0.05). Forearm sweat was negatively associated with the renin-toprorenin ratio and vanillylmandelic acid (VMA) excretion (P < 0.025), tests of sympathetic nerve function. The ratio of sweating in the forearm to sweating in the foot was likewise increased in diabetic patients with poor glycemic control. We interpret this redistribution of sudomotor responses to be indicative of sympathetic nerve injury and conclude 1) that the sympathetic nervous system is especially vulnerable to the adverse effects of chronic hyperglycemia and 2) that sympathetic dysfunction can be detected very early in type 1 diabetes. Diabetes 50: [436][437][438][439][440][441][442][443] 2001

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RR‐variation: The autonomic test of choice in diabetes

Cited by 107 publications

References 53 publications

Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites

Autonomic dysfunction and hyperdynamic circulation in cirrhosis with ascites

Hypoglycemia-associated autonomic failure in insulin-dependent diabetes mellitus. Recent antecedent hypoglycemia reduces autonomic responses to, symptoms of, and defense against subsequent hypoglycemia.

Redistribution of Sudomotor Responses Is an Early Sign of Sympathetic Dysfunction in Type 1 Diabetes

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