Körei Anna E, Kempler Miklós, Istenes Ildikó, Vági Orsolya E, Putz Zsuzsanna, Horváth Viktor J, Keresztes Katalin, Lengyel Csaba, Tabák Ádám Gy, Spallone Vincenza, Kempler Péter
1st Department of Medicine, Semmelweis University, 1083 Budapest, Korányi S utca 2/A, Hungary.
Curr Vasc Pharmacol. 2017;15(1):66-73. doi: 10.2174/1570161114666160822154351.
Historically, a set of 5 Cardiovascular Autonomic Reflex Tests (CARTs) were considered to be the gold standard in the assessment of Cardiovascular Autonomic Neuropathy (CAN). However, measuring diastolic Blood Pressure (BP) response to sustained handgrip is omitted in recent guidelines. We aimed to assess the association between the handgrip and the other 4 tests as well as to identify determinants of the handgrip test results in diabetic patients.
353 patients with diabetes (DM) were recruited (age: 60.2±7.4 years; female: 57.2%; BMI: 29.3±2.1 kg/m2; DM duration: 15.6±9.9 years; HbA1c: 7.8±1.4% (66 mmol/mol); with type 1 DM: 18.1%). CAN was assessed by 5 CARTs: the deep breathing test, Valsalva ratio, 30/15 ratio, handgrip and orthostatic hypotension test.
Sensitivity and specificity of the handgrip test in the diagnosis of definite CAN were 24.6% (95%CI 17.7-33.1%) and 79.4% (95%CI 73.3-84.4%), respectively. Results of the handgrip test did not show any association with those of the deep-breathing test (y=0.004, p=0.563), 30/15 ratio (y=0.282, p=0.357), Valsalva ratio (y=-0.058, p=0.436) and orthostatic hypotension (y=-0.026, p=0.833). Handgrip test abnormality showed an independent association with higher initial diastolic BP (OR 1.05, p=0.0009) and an independent inverse association with the presence of hypertension (OR=0.42, p=0.006).
Our data confirm that the handgrip test should no longer be part of the cardiovascular autonomic testing being highly dependent on hypertensive status and baseline diastolic BP. Exaggerated exercise pressor response is proposed as putative mechanism for the inverse association between abnormal results of the handgrip test and hypertension. Adequate CARTs are important to allow their use in clinical trials and for the prevention of DM-associated complications by initiating early treatment.
过去,一组5项心血管自主神经反射测试(CARTs)被认为是评估心血管自主神经病变(CAN)的金标准。然而,最近的指南中省略了测量舒张压(BP)对持续握力的反应。我们旨在评估握力测试与其他4项测试之间的关联,并确定糖尿病患者握力测试结果的决定因素。
招募了353例糖尿病(DM)患者(年龄:60.2±7.4岁;女性:57.2%;体重指数:29.3±2.1kg/m²;DM病程:15.6±9.9年;糖化血红蛋白:7.8±1.4%(66mmol/mol);1型DM患者:18.1%)。通过5项CARTs评估CAN:深呼吸测试、瓦尔萨尔瓦比值、30/15比值、握力测试和直立性低血压测试。
握力测试诊断明确CAN的敏感性和特异性分别为24.6%(95%可信区间17.7 - 33.1%)和79.4%(95%可信区间73.3 - 84.4%)。握力测试结果与深呼吸测试(y = 0.004,p = 0.563)、30/15比值(y = 0.282,p = 0.357)、瓦尔萨尔瓦比值(y = -0.058,p = 0.436)和直立性低血压(y = -0.026,p = 0.833)均无关联。握力测试异常与较高的初始舒张压呈独立关联(比值比1.05,p = 0.0009),与高血压的存在呈独立负相关(比值比 = 0.42,p = 0.006)。
我们的数据证实,握力测试高度依赖高血压状态和基线舒张压,不应再作为心血管自主神经测试的一部分。握力测试异常结果与高血压之间的负相关的假定机制是运动升压反应过度。适当的CARTs对于其在临床试验中的应用以及通过早期治疗预防DM相关并发症很重要。