Diabetology Department, Pitié-Salpêtrière-Charles Foix Hospital, AP-HP, 75013, Paris, France.
Sorbonne Université, Paris, France.
BMC Cardiovasc Disord. 2021 Mar 17;21(1):140. doi: 10.1186/s12872-021-01944-4.
Sudden cardiac deaths are twice more frequent in diabetic patients with cardiac autonomic neuropathy. Sudden cardiac death etiologies remain unclear and no recommendations are made to identify factors associated with cardiorespiratory arrest in diabetic patients. We hypothesized, from two clinical cases, that impaired hypoxic ventilatory drive, induced by diabetic autonomic neuropathy, is a cause of misdiagnosed severe cardiac events.
We describe the cases of two patients with isolated low blood saturation on pulse oximeter during the systematic nurse check-up (77% and 85% respectively) contrasting with the absence of any complaint such as dyspnea, polypnea or other respiratory insufficiency signs observed during the clinical examination. Arterial blood gas measurements subsequently confirmed that blood oxygen saturation was low and both patients were indeed hypoxemic. Patient 1 suffered from vascular overload complicated by cardiac arrest caused by hypoxemia in light of the quick recovery observed after ventilation. Pulmonary edema was diagnosed in patient 2. The common denominator of these 2 cases described in this brief report is the absence of respiratory failure clinical signs contrasting with the presence of confirmed hypoxemia. Also, in both cases, such absence of precursory signs seems to be induced by an impaired ventilatory drive to hypoxemia. This appears to be related to the autonomic diabetic neuropathy encountered in those 2 patients.
Therefore, we describe, in this brief report, cardiac autonomic neuropathy as a cause of impaired hypoxic ventilatory drive involved in severe acute cardiorespiratory events in two type 1 diabetic patients. We assume that altered response to hypoxemia due to cardiac autonomic neuropathy and non-functional central neurological breathing command could play a key role in sudden deaths among diabetic patients. An important point is that hypoxemia can be easily missed since no clinical signs of respiratory failure are reported in these two clinical cases. Systematic screening of cardiac autonomic neuropathy in diabetic patients and proactive detection of impaired hypoxic ventilatory drive for early management (e.g. treatment of hypoxemia) should be systematically undertaken in diabetic patients to prevent its dramatic consequences such as cardiorespiratory arrest and death.
患有心脏自主神经病变的糖尿病患者发生心源性猝死的频率是普通人群的两倍。心源性猝死的病因仍不清楚，也没有建议用于确定与糖尿病患者心搏骤停相关的因素。我们从两个临床病例中推测，由糖尿病自主神经病变引起的低氧通气驱动受损是误诊严重心脏事件的一个原因。
我们描述了两名患者的病例，他们在系统护士检查时脉搏血氧饱和度仪显示的血氧饱和度均较低（分别为 77%和 85%），但在临床检查过程中并未出现任何呼吸困难、呼吸急促或其他呼吸功能不全的症状。随后的动脉血气测量结果证实，血氧饱和度较低，两名患者均存在低氧血症。患者 1 因血管超负荷合并心搏骤停而住院，心搏骤停是由低氧血症引起的，好在通气后很快恢复。患者 2 被诊断为肺水肿。这两个病例的共同点是，尽管存在明确的低氧血症，但临床并无呼吸衰竭的迹象，而且在这两个病例中，这种无先兆体征似乎是由低氧通气驱动受损引起的。这似乎与这两名患者所患的糖尿病自主神经病变有关。
因此，我们在本简要报告中描述了心脏自主神经病变作为 2 型 1 型糖尿病患者严重急性心肺事件中低氧通气驱动受损的原因。我们假设，由于心脏自主神经病变导致的对低氧血症的反应改变以及非功能性中枢神经呼吸指令可能在糖尿病患者的猝死中起关键作用。一个重要的问题是，由于这两个临床病例中未报告呼吸衰竭的临床症状，因此很容易漏诊低氧血症。应该在糖尿病患者中系统筛查心脏自主神经病变，并主动检测低氧通气驱动受损，以便早期进行管理（例如治疗低氧血症），以防止其产生严重后果，如心搏骤停和死亡。
