Division of Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy.
Diabetes Metab J. 2019 Feb;43(1):3-30. doi: 10.4093/dmj.2018.0259.
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.
糖尿病心血管自主神经病变（CAN）的负担预计会随着糖尿病的流行及其早期和广泛出现而增加。CAN 对死亡率和心血管发病率有明确的预后作用。其潜在机制包括心动过速、QT 间期延长、直立性低血压、反向下降和心率变异性受损，而新兴的炎症机制则支持自主神经功能障碍的普遍性。目前正在努力克服 CAN 的漏诊问题：通过促进症状和体征的筛查；通过简化心血管反射测试；并通过选择筛查的候选人。CAN 评估可用于治疗其表现、心血管风险分层和调整治疗目标。CAN 的危险因素主要是 1 型糖尿病（T1DM）的血糖控制，此外，2 型糖尿病（T2DM）还包括高血压、血脂异常和肥胖，而初步数据则涉及血糖变异性、维生素 B12 和 D 变化、氧化应激、炎症和遗传生物标志物。血糖控制可预防 T1DM 中的 CAN，而多因素干预可能对 T2DM 有效。生活方式干预主要在糖尿病前期改善自主神经功能。虽然没有确凿的证据表明存在改变疾病的治疗方法，但可用于治疗 CAN 表现。SGLT2i 对自主神经功能的调节代表了一个有前途的研究领域，可能具有临床相关性。
