Valensi P, Huard J P, Giroux C, Attali J R
Department of Endocrinology-Diabetology-Nutrition, Jean Verdier Hospital, Paris-Nord University, Bond, France.
J Diabetes Complications. 1997 May-Jun;11(3):180-7. doi: 10.1016/s1056-8727(97)00005-6.
The role cardiac autonomic neuropathy (CAN) plays in diabetes is not well known. The aim of this study was to identify the factors involved in CAN in diabetic patients. One hundred patients, 44 insulin-dependent (IDDM) and 56 non-insulin-dependent (NIDDM), were investigated, using five standard tests. Three of these tests were for parasympathetic control (cardiac response to the lying-to-standing, deep breathing, and Valsalva tests), and the other two measured sympathetic control (testing for orthostatic hypotension and evaluating heart and blood pressure response to the handgrip test). Results were compared to those found in a series of 40 healthy volunteers. An age-adjusted comparison with the controls, showed that 34 patients had one abnormal parasympathetic test, 23 had two, and 6 patients had three. Cardiac parasympathetic neuropathy was thus present in 63% of the patients. The handgrip test was completed by 84 diabetic patients. There was evidence of orthostatic hypotension and/or an abnormal cardiac response to the handgrip in 15 of these patients, who all had a parasympathetic abnormality as well. There was no significant association between the type of diabetes and the presence of CAN. The duration of diabetes was significantly longer in patients with CAN (9.3 +/- 0.9 years) (p < 0.01) than in those with all three parasympathetic tests normal (5.8 +/- 0.9 years) (p < 0.01). The HbA1c level was also higher in patients with CAN than in those with three normal parasympathetic tests (9.95 +/- 0.35% versus 8.17 +/- 0.42%, p < 0.005). There was a significant association between the presence of retinopathy, observed by angiofluorography, and the presence of peripheral neuropathy confirmed by the electrophysiological investigation and the presence of CAN (p < 0.001). However, more than half the patients without retinopathy or nephropathy had CAN, and 11 of the 31 patients with a normal electrophysiological investigation also had CAN. Eighteen patients (6 IDDM) without retinopathy and nephropathy, who had been diabetic for less than 2 years, also had CAN. This study shows that CAN occurs early and is frequently found in a population of unselected diabetic patients. Metabolic factors may play an important role in its occurrence. CAN is significantly associated with the presence of retinopathy, which suggests that an impairment of autonomic peripheral blood flow control might be a contributing factor in the formation of microvascular lesions.
心脏自主神经病变（CAN）在糖尿病中所起的作用尚不明确。本研究旨在确定糖尿病患者中CAN的相关因素。对100例患者进行了研究，其中44例为胰岛素依赖型糖尿病（IDDM），56例为非胰岛素依赖型糖尿病（NIDDM），采用了五项标准测试。其中三项测试用于评估副交感神经控制（心脏对平卧位到站立位、深呼吸和瓦尔萨尔瓦动作测试的反应），另外两项测量交感神经控制（检测直立性低血压以及评估心脏和血压对手握力测试的反应）。将结果与40名健康志愿者的结果进行比较。经年龄校正后与对照组比较，结果显示34例患者有一项副交感神经测试异常，23例有两项异常，6例有三项异常。因此，63%的患者存在心脏副交感神经病变。84例糖尿病患者完成了握力测试。其中15例患者存在直立性低血压和/或握力测试时心脏反应异常，这些患者也均有副交感神经异常。糖尿病类型与CAN的存在之间无显著关联。CAN患者的糖尿病病程（9.3±0.9年）（p<0.01）显著长于三项副交感神经测试均正常的患者（5.8±0.9年）（p<0.01）。CAN患者的糖化血红蛋白（HbA1c）水平也高于三项副交感神经测试正常的患者（分别为9.95±0.35%和8.17±0.42%，p<0.005）。通过血管荧光造影观察到的视网膜病变的存在、经电生理检查证实的周围神经病变的存在与CAN的存在之间存在显著关联（p<0.001）。然而，超过一半没有视网膜病变或肾病的患者有CAN，31例电生理检查正常患者中有11例也有CAN。18例（其中6例为IDDM）无视网膜病变和肾病且糖尿病病程小于2年的患者也有CAN。本研究表明，CAN在未经过筛选的糖尿病患者群体中出现较早且较为常见。代谢因素可能在其发生中起重要作用。CAN与视网膜病变的存在显著相关，这表明自主神经外周血流控制受损可能是微血管病变形成的一个促成因素。
