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Sheikh AB, Sobotka PA, Garg I, Dunn JP, Minhas AMK, Shandhi MMH, Molinger J, McDonnell BJ, Fudim M. Blood Pressure Variability in Clinical Practice: Past, Present and the Future. J Am Heart Assoc 2023; 12:e029297. [PMID: 37119077 PMCID: PMC10227216 DOI: 10.1161/jaha.122.029297] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Recent advances in wearable technology through convenient and cuffless systems will enable continuous, noninvasive monitoring of blood pressure (BP), heart rate, and heart rhythm on both longitudinal 24-hour measurement scales and high-frequency beat-to-beat BP variability and synchronous heart rate variability and changes in underlying heart rhythm. Clinically, BP variability is classified into 4 main types on the basis of the duration of monitoring time: very-short-term (beat to beat), short-term (within 24 hours), medium-term (within days), and long-term (over months and years). BP variability is a strong risk factor for cardiovascular diseases, chronic kidney disease, cognitive decline, and mental illness. The diagnostic and therapeutic value of measuring and controlling BP variability may offer critical targets in addition to lowering mean BP in hypertensive populations.
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Affiliation(s)
- Abu Baker Sheikh
- Department of Internal MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNMUSA
| | - Paul A. Sobotka
- Division of CardiologyDuke University Medical CenterDurhamNCUSA
| | - Ishan Garg
- Department of Internal MedicineUniversity of New Mexico Health Sciences CenterAlbuquerqueNMUSA
| | - Jessilyn P. Dunn
- Department of Biomedical EngineeringDuke UniversityDurhamNCUSA
- Department of Biostatistics & BioinformaticsDuke UniversityDurhamNCUSA
| | | | | | | | - Barry J. McDonnell
- Department of Biomedical ResearchCardiff Metropolitan UniversitySchool of Sport and Health SciencesCardiffUnited Kingdom
| | - Marat Fudim
- Division of CardiologyDuke University Medical CenterDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
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2
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Association of Non-Dipping Blood Pressure Patterns with Diabetic Peripheral Neuropathy: A Cross-Sectional Study among a Population with Diabetes in Greece. Nutrients 2022; 15:nu15010072. [PMID: 36615728 PMCID: PMC9824387 DOI: 10.3390/nu15010072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/11/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Diabetic peripheral neuropathy (DPN) is present in 20-50% of cases with diabetes. The pathophysiology of DPN is not yet clear regarding hypertension (HTN). The aim of this study was to assess the association between the stages of DPN and HTN in a Greek population with diabetes. We examined 102 adults for diabetic neuropathy (DPN) from November 2020 to December 2021, using the Toronto Clinical Neuropathy Scale System (TCNSS) to categorize them into two groups (no/mild DPN versus medium/severe DPN). Ambulatory blood pressure monitoring was performed to evaluate their hypertensive status. Univariate and multivariate logistic regression analyses were performed to assess the association between the stage of DPN and HTN. The multivariate analysis, considering sex, age, and dipping status, did not show statistically significant associations between stages of HTN and DPN. However, in contrast to dippers, non-dippers had an almost four-times higher risk of developing medium-to-severe DPN (odds ratio (OR) 3.93; 95% confidence interval (CI) [1.33-11.64]); females, in contrast to males, had a 65% lower risk of developing moderate/severe DPN (OR 0.35; 95%CI [0.14-0.92]). In conclusion, our findings showed no statistically significant associations between DPN and HTN; however, dipping status, hyperglycemia, and female sex were shown to play a role in the pathophysiology of DPN.
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Rasmussen TK, Finnerup NB, Singer W, Jensen TS, Hansen J, Terkelsen AJ. Preferential impairment of parasympathetic autonomic function in type 2 diabetes. Auton Neurosci 2022; 243:103026. [PMID: 36137485 DOI: 10.1016/j.autneu.2022.103026] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cardiovascular autonomic neuropathy is a known complication in type 2 diabetes (T2D). However, the extent of sympathetic dysfunction and its relation to blood pressure (BP) dysregulation is insufficiently studied. We therefore assessed the cardiovascular sympathetic function using a standardized autonomic test-battery. RESEARCH DESIGN AND METHODS Forty T2D patients (mean age and duration of diabetes ±SD, 65.5 ± 7.3 and 9.5 ± 4.2 years) and 40 age- and gender-matched controls were examined through autonomic testing, assessing cardiovascular responses to deep breathing, Valsalva maneuver and tilt-table testing. Additionally, 24-hour oscillometric BP and self-reported autonomic symptoms on COMPASS-31 questionnaire was recorded. RESULTS Patients with T2D had reduced parasympathetic activity with reduced deep breathing inspiratory:expiratory-ratio (median [IQR] T2D 1.11 [1.08-1.18] vs. controls 1.18 [1.11-1.25] (p = 0.01)), and reduced heart rate variability (p < 0.05). We found no differences in cardiovascular sympathetic function measured through BP responses during the Valsalva maneuver (p > 0.05). 24-hour-BP detected reduced night-time systolic BP drop in T2D (9.8 % ± 8.8 vs. controls 15.8 % ± 7.7 (p < 0.01)) with more patients having reverse dipping. Patients with T2D reported more symptoms of orthostatic intolerance on the COMPASS-31 (p = 0.04). CONCLUSIONS Patients with T2D showed reduced parasympathetic activity but preserved short-term cardiovascular sympathetic function, compared to controls, indicating autonomic dysfunction with predominantly parasympathetic impairment. Despite this, T2D patients reported more symptoms of orthostatic intolerance in COMPASS-31 and had reduced nocturnal BP dipping, indicating that these are not a consequence of cardiovascular sympathetic dysfunction.
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Affiliation(s)
- Thorsten K Rasmussen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
| | | | - Troels S Jensen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - John Hansen
- Department of Health Science and Technology, Aalborg University, Denmark
| | - Astrid J Terkelsen
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, Denmark; International Diabetic Neuropathy Consortium (IDNC), Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Neurology, Aarhus University Hospital, Denmark
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Hjortkjær HØ, Persson F, Theilade S, Winther SA, Tofte N, Ahluwalia TS, Rossing P. Non-dipping and higher nocturnal blood pressure are associated with risk of mortality and development of kidney disease in type 1 diabetes. J Diabetes Complications 2022; 36:108270. [PMID: 35964524 DOI: 10.1016/j.jdiacomp.2022.108270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 07/02/2022] [Accepted: 07/24/2022] [Indexed: 11/19/2022]
Abstract
AIMS People with type 1 diabetes have increased risk of cardiovascular (CV) and kidney disease. A 24-hour ambulatory blood pressure (BP) measurement (ABPM) examines diurnal variations in BP. We aimed to determine the prognostic significance of blunted decrease in nocturnal systolic BP of <10 % (non-dipping of nocturnal BP) for CV- and kidney disease and all-cause mortality in type 1 diabetes. METHODS From 2009 to 2011, at Steno Diabetes Center Copenhagen, 654 participants with type 1 diabetes had 24-hour ABPM obtained with a tonometric wrist-watch device (BPro, HealthStats, Singapore). In 2017, outcomes (composite CV endpoint; all-cause mortality; decline in estimated glomerular filtration rate (eGFR) ≥30 %; end-stage kidney disease (ESKD); and a composite kidney endpoint including decline in eGFR ≥30 %, ESKD and all-cause mortality) were registered. Hazard Ratios (HR) were calculated using Cox regressions. RESULTS Participants were mean ± SD 55 ± 13 years old and had median (IQR) 35 (24-44) years diabetes duration. Mean daytime and nocturnal systolic BP were 133 ± 16 and 121 ± 16 mmHg while 337 (52 %) participants demonstrated non-dipping. After CV risk factor adjustments, non-dipping was associated with all-cause mortality (HR 2.12 (1.09-4.11), p = 0.03) and the composite kidney endpoint (HR 1.92 (1.23-3.00), p = 0.004). CONCLUSIONS Non-dipping entailed increased risk of all-cause mortality and kidney disease in type 1 diabetes.
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Affiliation(s)
| | | | - Simone Theilade
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Department of Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Signe A Winther
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Novo Nordisk A/S, Søborg, Denmark
| | - Nete Tofte
- Steno Diabetes Center Copenhagen, Herlev, Denmark; Novo Nordisk A/S, Søborg, Denmark
| | - Tarunveer S Ahluwalia
- Steno Diabetes Center Copenhagen, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; University of Copenhagen, Copenhagen, Denmark
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Delsart P, Lemaitre M, Vambergue A, Ninni S, Bauters C, Ledieu G, Eymard DF, Baudoux F, Le Chevalier De Preville A, Sobocinski J, Montaigne D, Mounier-Vehier C. Prognostic significance of reverse dipping status on lower limb event in type 2 diabetic patients without peripheral arterial disease. Acta Diabetol 2022; 59:843-850. [PMID: 35333978 DOI: 10.1007/s00592-022-01879-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/08/2022] [Indexed: 11/01/2022]
Abstract
AIMS We assessed reverse dipping influence on the risk of lower limb events in type 2 diabetic patients without peripheral arterial disease. METHODS Patients with type 2 diabetes addressed for cardiovascular risk stratification in our university hospital from 2008 to 2012 underwent 24 h blood pressure monitoring. Patients with a prior history of limb revascularization or with a stenosis > 50% of the legs were excluded. Reverse dipping was defined as a greater night-versus day-time systolic blood pressure. The endpoint was the first occurrence of lower limb revascularization or limb amputation. Hazard ratios (HRs) and 95% confidence intervals were calculated using the Cox model. RESULTS Two hundred and eighty-one patients were included. During a median follow-up of 9.4 [7.7-10.6] years, 20 lower limb events and 45 all-cause deaths were observed. Thirty-five patients were reverse dippers. The reverse dipping status was associated with lower limb events when considering all-cause death as a competitive risk, (HR 3.61 [1.16-11.2], P = 0.026). Reverse dipping, HbA1C and proteinuria were independently associated with lower limb outcome in a multivariable analysis (respectively HR 4.09 [1.29-12.9], P = 0.017, HR 1.30 [1.04-1.63], P = 0.022 and HR 1.06 [1.02-1.11], P = 0.001). CONCLUSIONS Reverse dipping status is independently associated with worse limb outcome in type 2 diabetic patients.
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Affiliation(s)
- Pascal Delsart
- CHU Lille, Vascular Medicine and Hypertension Department, Institut Cœur Poumon, Boulevard Pr Leclercq, 59000, Lille, France.
| | - Madleen Lemaitre
- Endocrinology, Diabetology and Metabolism, CHU Lille, 59000, Lille, France
| | - Anne Vambergue
- Endocrinology, Diabetology and Metabolism, CHU Lille, 59000, Lille, France
| | - Sandro Ninni
- Inserm U1011, CHU Lille, Institut Pasteur de Lille, EGID, Univ. Lille, 59000, Lille, France
| | - Christophe Bauters
- Inserm U1167, CHU Lille, Institut Pasteur, Univ. Lille, 59000, Lille, France
| | - Guillaume Ledieu
- CHU Lille, Vascular Medicine and Hypertension Department, Institut Cœur Poumon, Boulevard Pr Leclercq, 59000, Lille, France
| | - Diane-Flore Eymard
- CHU Lille, Vascular Medicine and Hypertension Department, Institut Cœur Poumon, Boulevard Pr Leclercq, 59000, Lille, France
| | - Florence Baudoux
- Endocrinology, Diabetology and Metabolism, CHU Lille, 59000, Lille, France
| | | | | | - David Montaigne
- Inserm U1011, CHU Lille, Institut Pasteur de Lille, EGID, Univ. Lille, 59000, Lille, France
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6
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Min JW, Chang JY, Lee H, Park Y, Ko EJ, Cho JH, Yang CW, Chung BH. Clinical significance of heart rate variability for the monitoring of cardiac autonomic neuropathy in end-stage renal disease patients. Nutr Metab Cardiovasc Dis 2021; 31:2089-2098. [PMID: 33975739 DOI: 10.1016/j.numecd.2021.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 02/01/2021] [Accepted: 03/17/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIMS The aim of this study is to determine whether the measurement of continuous heart rate variability (HRV) is useful in the evaluation of cardiac autonomic neuropathy (CAN) in end-stage renal disease (ESRD) patients. METHODS AND RESULTS This cross-sectional study was performed at Seoul St. Mary's hospital between June 2017 and February 2018. Seventy-seven ESRD patients, and 29 healthy controls (HCs) were asked to wear a continuous ambulatory HRV monitor for 24 h. General cardiac function was evaluated using transthoracic echocardiogram (TTE), pulse wave velocity (PWV), coronary calcium scoring (CCS), and 24-h ambulatory blood pressure monitoring (ABPM). HRV parameters of ESRD patients and HCs, and the correlation of HRV parameters with cardiovascular screening methods were observed. All HRV parameters were significantly decreased in ESRD patients compared to HCs (P < 0.001). In the correlation analysis between TTE results and HRV parameters, 24-h standard deviation of all N-N intervals (24SDNN), 24-h standard deviation of sequential 5-min N-N interval means (24DANN) and Low Frequency Power/High Frequency Power (LF/HF) ratio showed negative correlations with E/e', LAVI and TR velocity which are representative indices for the diastolic function of the heart (P < 0.05). HRV parameters showed negative correlations with baPWV, CCS, and 24-h ABPM results as well (P < 0.05). Hemoglobin and serum albumin showed positive correlations with HRV parameters, and glucose, BUN, creatinine, and iPTH levels showed negative correlations (P < 0.05). CONCLUSION Continuous HRV monitoring may be a useful tool for the evaluation of CAN in ESRD.
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Affiliation(s)
- Ji Won Min
- Division of Nephrology, Department of Internal Medicine, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Ji-Yeun Chang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hanbi Lee
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Yohan Park
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Eun Jeong Ko
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Jae Hyoung Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Chul Woo Yang
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Ha Chung
- Division of Nephrology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea.
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7
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Ryu JW, Cha RH, Lee H, Kim YS, Lee JP, Song YR, Kim SG, Kim SJ. Association of Blood Pressure at Specific Time-Points with 1-Year Renal Outcomes in Patients with Diabetic Chronic Kidney Disease. Electrolyte Blood Press 2020; 17:36-44. [PMID: 31969922 PMCID: PMC6962443 DOI: 10.5049/ebp.2019.17.2.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/19/2019] [Accepted: 11/26/2019] [Indexed: 11/05/2022] Open
Abstract
Background The 24-hour mean blood pressure (mBP) is the best predictor of organ damage; however, it is not easily applicable in clinical practice. The APrODiTe study suggested that systolic blood pressure (SBP) values at 7:00 AM and 9:30 PM were associated with the 24-hour mSBP in patients with chronic kidney disease (CKD). We investigated the association of the SBP values at these time-points with the renal outcomes in patients with diabetic CKD during 1-year follow-up. Methods Ninety-six patients with diabetic CKD were included at 1-year follow-up. The renal outcomes were an increase in the random urine protein/creatinine ratio or estimated glomerular filtration rate (eGFR) deterioration, which means a decrease in eGFR ≥5 mL/min/1.73 m2 compared to the baseline values. Results The baseline SBP values at 7:00 AM, and 9:30 PM, and the 24-hour mSBP were 135.6±24.9 mmHg, 141.7±25.6 mmHg, and 136.4±20.7 mmHg, respectively. The SBP values measured at the same time-points after 1 year were similar to those at baseline. The SBP at 7:00 AM was significantly associated with eGFR deterioration in the univariate and multivariate analyses (odds ratio [OR]: 1.032; 95% confidence interval [CI]: 1.006-1.059; p=0.016). The SBP at 7:00AM and 24-hour mSBP did not show a concordant association with sustained proteinuria in the linear and logistic analyses. In the subgroup analysis, the association between the SBP at 7:00 AM and eGFR deterioration persisted in patients with CKD stage 3-5 (OR: 1.041; 95% CI: 1.010-1.073; p=0.010). Conclusion The SBP at 7:00 AM, in addition to the 24-hour mSBP, is also associated with eGFR deterioration in patients with diabetic CKD, particularly in those with CKD stage 3-5.
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Affiliation(s)
- Ji Won Ryu
- Department of Internal Medicine, Cheju Halla General Hospital, Cheju, Korea
| | - Ran-Hui Cha
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Yon Su Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Kidney Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
| | - Jung Pyo Lee
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul, Korea
| | - Young Rim Song
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Sung Gyun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Se Joong Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.,Kidney Research Institute, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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8
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Abstract
PURPOSE OF REVIEW This review considers the relationship between abnormal blood pressure (BP) variability and autonomic dysfunction through an attempt to answer questions about its clinical relevance and pertinence to diabetes and cardiovascular autonomic neuropathy (CAN) and which therapeutic measures can lessen its cardiovascular impact. RECENT FINDINGS Office, ambulatory, and home BP monitoring identify posture-related, circadian, short-term, and long-term BP variabilities. Abnormal BP variability is a risk marker for organ damage, mortality, and cardiovascular events. Moreover, BP variability changes are common in diabetes and associated with CAN and possibly exacerbated by comorbidities like nephropathy, obstructive sleep apnoea syndrome, and chronic pain. The prognostic role of nondipping and reverse dipping is well documented in diabetes. Some findings suggest the possibility of restoring dipping with the dosage time of antihypertensive agents. Diabetes is a favorable scenario for altered BP variability, which might mediate the harmful effects of CAN. Preliminary data suggest the protective effect of targeting BP variability. However, further longitudinal outcome studies are needed. In the meantime, BP variability measures and practical expedients in antihypertensive treatment should be implemented in diabetes.
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Affiliation(s)
- Vincenza Spallone
- Endocrinology, Department of Systems Medicine, University of Rome Tor Vergata, Via Montpellier, 1, 00133, Rome, Italy.
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9
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Najafi MT, Khaloo P, Alemi H, Jaafarinia A, Blaha MJ, Mirbolouk M, Mansournia MA, Afarideh M, Esteghamati S, Nakhjavani M, Esteghamati A. Ambulatory blood pressure monitoring and diabetes complications: Targeting morning blood pressure surge and nocturnal dipping. Medicine (Baltimore) 2018; 97:e12185. [PMID: 30235664 PMCID: PMC6160188 DOI: 10.1097/md.0000000000012185] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Ambulatory blood pressure monitoring (ABPM) correlates more closely to organ damages than clinic blood pressure (BP). In the current study we aimed to investigate the association between micro- and macrovascular complications of diabetes and both diurnal and nocturnal variability in BP.A total of 192 patients with type 2 diabetes (T2DM) who had complete data on ABPM were selected. BP categories were defined based on 2017 ACC/American Heart Association BP guideline. The cross-sectional association between different BP phenotypes and diabetes complications including cardiovascular disease (CVD), nephropathy, retinopathy, and neuropathy was assessed using multiple logistic regression models adjusted for age, sex, body mass index, hypertension (HTN), hemoglobin A1c, fasting blood glucose (FBG), triglyceride (TG), high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and total cholesterol.Approximately 48.9% of participants with T2DM had 24-hour HTN. The prevalence of daytime, nighttime, and clinic HTN were 35.9%, 96.3%, and 53.1%, respectively. Approximately 54.2% of participants had nondipping nocturnal pattern and 28.6% were risers. Nondipping nocturnal BP was associated with CVD, neuropathy, and retinopathy (P = .05, .05, and .014, respectively). Sleep trough morning blood pressure surge (MBPS) was associated with neuropathy (P = .023). Neuropathy was also associated with other components of MBPS (P < .05).We demonstrated that diabetic neuropathy was associated with all the components of MBPS and abnormal dipping status. Our results indicated loss of nocturnal BP dipping but not MBPS as a risk factor for CVD and retinopathy in patients with T2DM. Our findings once again highlighted the importance of ambulatory BP monitoring and targeted antihypertensive therapy directed toward to restore normal circadian BP in patients with T2DM.
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Affiliation(s)
| | - Pegah Khaloo
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
| | - Hamid Alemi
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
| | - Asma Jaafarinia
- Department of Nephrology, Shahid Rahnemoon Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Michael J. Blaha
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, MD
| | - Mohammadhassan Mirbolouk
- Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins Hospital, Baltimore, MD
| | - Mohammad Ali Mansournia
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Afarideh
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
| | - Sadaf Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
| | - Manouchehr Nakhjavani
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
| | - Alireza Esteghamati
- Endocrinology and Metabolism Research Center (EMRC), Vali-Asr Hospital, School of Medicine, Tehran University of Medical Sciences, Tehran
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10
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Casali KR, Schaan BD, Montano N, Massierer D, M F Neto F, Teló GH, Ledur PS, Reinheimer M, Sbruzzi G, Gus M. Correlation between Very Short and Short-Term Blood Pressure Variability in Diabetic-Hypertensive and Healthy Subjects. Arq Bras Cardiol 2018; 110:157-165. [PMID: 29561993 PMCID: PMC5855909 DOI: 10.5935/abc.20180020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 07/21/2017] [Indexed: 12/19/2022] Open
Abstract
Background Blood pressure (BP) variability can be evaluated by 24-hour ambulatory BP
monitoring (24h-ABPM), but its concordance with results from finger BP
measurement (FBPM) has not been established yet. Objective The aim of this study was to compare parameters of short-term (24h-ABPM) with
very short-term BP variability (FBPM) in healthy (C) and
diabetic-hypertensive (DH) subjects. Methods Cross-sectional study with 51 DH subjects and 12 C subjects who underwent
24h-ABPM [extracting time-rate, standard deviation (SD), coefficient of
variation (CV)] and short-term beat-to-beat recording at rest and after
standing-up maneuvers [FBPM, extracting BP and heart rate (HR) variability
parameters in the frequency domain, autoregressive spectral analysis].
Spearman correlation coefficient was used to correlate BP and HR variability
parameters obtained from both FBPM and 24h-ABPM (divided into daytime,
nighttime, and total). Statistical significance was set at p < 0.05. Results There was a circadian variation of BP levels in C and DH groups; systolic BP
and time-rate were higher in DH subjects in all periods evaluated. In C
subjects, high positive correlations were shown between time-rate index
(24h-ABPM) and LF component of short-term variability (FBPM, total, R =
0.591, p = 0.043); standard deviation (24h-ABPM) with LF component BPV
(FBPM, total, R = 0.608, p = 0.036), coefficient of variation (24h-ABPM)
with total BPV (FBPM, daytime, -0.585, p = 0.046) and alpha index (FBPM,
daytime, -0.592, p = 0.043), time rate (24h-ABPM) and delta LF/HF (FBPM,
total, R = 0.636, p = 0.026; daytime R = 0,857, p < 0.001). Records
obtained from DH showed weak positive correlations. Conclusions Indices obtained from 24h-ABPM (total, daytime) reflect BP and HR
variability evaluated by FBPM in healthy individuals. This does not apply
for DH subjects.
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Affiliation(s)
- Karina R Casali
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Beatriz D Schaan
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil.,Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brazil
| | | | - Daniela Massierer
- Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brazil
| | - Flávio M F Neto
- Serviço de Cardiologia - Hospital de Clinicas de Porto Alegre, Porto Alegre, RS - Brazil
| | - Gabriela H Teló
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
| | - Priscila S Ledur
- Universidade Federal do Rio Grande do Sul, Porto Alegre, RS - Brazil
| | - Marilia Reinheimer
- Serviço de Cardiologia - Hospital de Clinicas de Porto Alegre, Porto Alegre, RS - Brazil
| | - Graciele Sbruzzi
- Instituto de Cardiologia - Fundação Universitária de Cardiologia (IC/FUC), Porto Alegre, RS - Brazil
| | - Miguel Gus
- Divisão de Cardiologia - Hospital de Clínicas de Porto Alegre, Porto Alegre, RS - Brazil
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11
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Bissinger A. Cardiac Autonomic Neuropathy: Why Should Cardiologists Care about That? J Diabetes Res 2017; 2017:5374176. [PMID: 29214181 PMCID: PMC5682059 DOI: 10.1155/2017/5374176] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 05/06/2017] [Accepted: 05/21/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Cardiac autonomic neuropathy (CAN) is a frequent but underdiagnosed complication of diabetes mellitus. It has a strong influence on various cardiac disorders including myocardial ischemia and infarction, hypertension, orthostatic hypotonia, heart failure, and arrhythmias. CAN can lead to severe morbidity and mortality and increase the risk of sudden cardiac death. METHODS This review article summarizes the latest evidence regarding the epidemiology, pathogenesis, influence on the cardiovascular system, and diagnostic methods for CAN. The methodology of this review involved analyzing available data from recent papers relevant to the topic of diabetic autonomic neuropathy and cardiac disorders. CONCLUSIONS The early diagnosis of CAN can improve the prognosis and reduce adverse cardiac events. Methods based on heart rate variability enable the diagnosis of CAN even at a preclinical stage. These methods are simple and widely available for use in everyday clinical practice. According to the recently published Toronto Consensus Panel on Diabetic Neuropathy, all diabetic patients should be screened for CAN. Because diabetes mellitus often coexists with heart diseases and the most common methods used for diagnosis of CAN are based on ECG, not only diabetologists but also cardiologists should be responsible for diagnosis of CAN.
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Affiliation(s)
- Andrzej Bissinger
- Department of Interventional Cardiology and Arrhythmias, Medical University of Lodz, Lodz, Poland
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12
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Hjortkjær HØ, Jensen T, Kofoed KF, Mogensen UM, Sigvardsen PE, Køber L, Hilsted KL, Corinth H, Theilade S, Hilsted J. Nocturnal antihypertensive treatment in patients with type 1 diabetes with autonomic neuropathy and non-dipping: a randomised, placebo-controlled, double-blind cross-over trial. BMJ Open 2016; 6:e012307. [PMID: 27920083 PMCID: PMC5168694 DOI: 10.1136/bmjopen-2016-012307] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES Cardiovascular autonomic neuropathy (CAN) and abnormal circadian blood pressure (BP) rhythm are independent cardiovascular risk factors in patients with diabetes and associations between CAN, non-dipping of nocturnal BP and coronary artery disease have been demonstrated. We aimed to test if bedtime dosing (BD) versus morning dosing (MD) of the ACE inhibitor enalapril would affect the 24-hour BP profile in patients with type 1 diabetes (T1D), CAN and non-dipping. SETTING Secondary healthcare unit in Copenhagen, Denmark. PARTICIPANTS 24 normoalbuminuric patients with T1D with CAN and non-dipping were included, consisting of mixed gender and Caucasian origin. Mean±SD age, glycosylated haemoglobin and diabetes duration were 60±7 years, 7.9±0.7% (62±7 mmol/mol) and 36±11 years. INTERVENTIONS In this randomised, placebo-controlled, double-blind cross-over study, the patients were treated for 12 weeks with either MD (20 mg enalapril in the morning and placebo at bedtime) or BD (placebo in the morning and 20 mg enalapril at bedtime), followed by 12 weeks of switched treatment regimen. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome was altered dipping of nocturnal BP. Secondary outcomes included a measurable effect on other cardiovascular risk factors than BP, including left ventricular function (LVF). RESULTS Systolic BP dipping increased 2.4% (0.03-4.9%; p=0.048) with BD compared to MD of enalapril. There was no increase in mean arterial pressure dipping (2.2% (-0.1% to 4.5%; p=0.07)). No difference was found on measures of LVF (p≥0.15). No adverse events were registered during the study. CONCLUSIONS We demonstrated that patients with T1D with CAN and non-dipping can be treated with an ACE inhibitor at night as BD as opposed to MD increased BP dipping, thereby diminishing the abnormal BP profile. The potentially beneficial effect on long-term cardiovascular risk remains to be determined. TRIAL REGISTRATION NUMBER EudraCT2012-002136-90; Post-results.
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Affiliation(s)
- Henrik Øder Hjortkjær
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Klaus F Kofoed
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik M Mogensen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Lisa Hilsted
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Helle Corinth
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Jannik Hilsted
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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13
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Cashion AK, Cowan PA, Milstead EJ, Gaber AO, Hathaway DK. Heart Rate Variability, Mortality, and Exercise in Patients with End-Stage Renal Disease. Prog Transplant 2016. [DOI: 10.1177/152692480001000103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Context Cardiac autonomic function has been associated with mortality in patients with end-stage renal disease. It is unknown whether end-stage renal disease patients who have succumbed to sudden cardiac death can be better identified by a newer test of heart rate variability that uses spectral analysis, rather than laboratory evoked measures. Objective This series of studies sought to characterize cardiac autonomic function in patients awaiting kidney transplantation, identify factors associated with heart rate variability, identify tests which distinguish patients at-risk for death, and compare evoked measures with 24-hour heart rate variability measures. Patients Data were collected on 184 nondiabetics, 60 type 1 diabetics, and 34 type 2 diabetics with end-stage renal disease, all of whom had been referred for kidney transplantation. Main Outcome Measures The 278 patients and 67 healthy control subjects underwent evoked tests (changes in heart rate with deep breathing and Valsalva maneuver) and 24-hour heart rate variability Holter monitoring (time and frequency domains). Five patients had sudden cardiac deaths during the study. Results Data showed that end-stage renal disease patients, particularly diabetics, had compromised autonomic function. The standard deviation of all R-to-R intervals for the electrocardiogram recording (<50 minutes in 60% of the deceased patients), a 24-hour heart rate variability time domain measure, holds the promise of identifying patients at increased risk for death. Exercise was identified as a factor associated with better autonomic function. Examining relationships between 24-hour heart rate variability and characteristics of patients who succumb to death could make quantification of the mortality risk for individual pretransplant end-stage renal disease patients possible, much as it has in other populations. The data from this study may also make it possible to design interventions, such as exercise, aimed at reducing mortality risk.
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Affiliation(s)
- Ann K. Cashion
- College of Nursing, University of Tennessee, Memphis (AKC, PAC, EJM, DKH), College of Medicine, University of Tennessee, Memphis (AOG)
| | - Patricia A. Cowan
- College of Nursing, University of Tennessee, Memphis (AKC, PAC, EJM, DKH), College of Medicine, University of Tennessee, Memphis (AOG)
| | - E. Jean Milstead
- College of Nursing, University of Tennessee, Memphis (AKC, PAC, EJM, DKH), College of Medicine, University of Tennessee, Memphis (AOG)
| | - A. Osama Gaber
- College of Nursing, University of Tennessee, Memphis (AKC, PAC, EJM, DKH), College of Medicine, University of Tennessee, Memphis (AOG)
| | - Donna K. Hathaway
- College of Nursing, University of Tennessee, Memphis (AKC, PAC, EJM, DKH), College of Medicine, University of Tennessee, Memphis (AOG)
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14
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Costa A, Bosone D, Ramusino MC, Ghiotto N, Guaschino E, Zoppi A, D'Angelo A, Fogari R. Twenty-four-hour blood pressure profile, orthostatic hypotension, and cardiac dysautonomia in elderly type 2 diabetic hypertensive patients. Clin Auton Res 2016; 26:433-439. [PMID: 27624333 DOI: 10.1007/s10286-016-0381-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 07/24/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE The aim of this study was to evaluate the relationship between orthostatic hypotension (OH), defined as a decrease in systolic blood pressure (SBP) ≥20 mmHg and/or a decrease in diastolic blood pressure (DBP) ≥10 mmHg, and 24-h ambulatory BP profile in elderly hypertensive type 2 diabetic patients. METHODS After a 2-week antihypertensive wash-out period, 200 hypertensive well-controlled diabetic outpatients, aged 65-75 years, underwent a clinical examination, including BP measurements, ECG, 24-h ABP monitoring (ABPM), an orthostatic test, and three tests for cardiovascular autonomic function assessment [deep breathing, heart rate (HR) variability, resting HR]. RESULTS According to their nighttime BP profile, patients were divided into three groups: dippers (n = 86) (BP fall during nighttime ≥10 %), non-dippers (n = 80) (BP fall during nighttime 0-10 %), and reverse dippers (n = 34) (nighttime BP > daytime BP). Orthostatic test produced a significantly greater orthostatic SBP fall in dippers and even more in reverse dippers. In these latter, a significant fall was observed also in DBP. Prevalence of OH was 9.3 % in dippers, 30 % in non-dippers, and 79.4 % in reverse dippers. CONCLUSIONS In elderly hypertensive type 2 diabetics, a blunted nocturnal BP fall is associated with OH and autonomic dysfunction. These data suggest that ABPM should be performed in the assessment of hypertensive diabetic patients in whom the cardiovascular dysautonomia is suspected or the signs of it are present (such as OH).
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Affiliation(s)
- Alfredo Costa
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Daniele Bosone
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Matteo Cotta Ramusino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Natascia Ghiotto
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Elena Guaschino
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Annalisa Zoppi
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Angela D'Angelo
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy
| | - Roberto Fogari
- Department of Neurosciences and Behavior, National Institute of Neurology IRCCS C. Mondino Foundation, University of Pavia, Via Mondino, 2, 27100, Pavia, Italy.
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15
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Massierer D, Leiria LF, Severo MD, Ledur PDS, Becker AD, Aguiar FM, Lima E, Freitas VC, Schaan BD, Gus M. Blood pressure variability and its association with echocardiographic parameters in hypertensive diabetic patients. BMC Cardiovasc Disord 2016; 16:4. [PMID: 26747793 PMCID: PMC4706684 DOI: 10.1186/s12872-015-0183-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 12/31/2015] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Blood pressure (BP) variability is associated with target organ damage in hypertension and diabetes. The 24 h ambulatory blood pressure monitoring (24 h-ABPM) has been proposed as an evaluation for BP variability using several indexes [standard deviation (SD) of mean BP, coefficient of variation (CV), BP variation over time (time-rate index)]. METHODS We evaluated the association between BP variability measured by 24 h-ABPM indexes and echocardiographic variables in a cross-sectional study in 305 diabetic-hypertensive patients. RESULTS Two groups were defined by the median (0.55 mmHg/min) of time-rate systolic BP (SBP) index and classified as low or high variability. Age was 57.3 ± 6.2 years, 196 (64.3%) were female. Diabetes duration was 10.0 (5.0-16.2) years, HbA1c was 8.2 ± 1.9%. Baseline clinical characteristics were similar between low (n = 148) and high (n = 157) variability groups. Office SBP and systolic 24 h-ABPM were higher in the high variability group (139.9 mmHg vs 146.0 mmHg, P = 0.006; 128.3 mmHg vs 132.9 mmHg, P = 0.019, respectively). Time-rate index, SD and CV of SBP, were higher in high variability group (P < 0.001; P < 0.001 and P = 0.003, respectively). Time-rate index was not independently associated with the echocardiography's variables in multiple linear model when adjusting for age, 24 h-ABPM, diabetes duration and HbA1c. The multiple linear regression model revealed that the significant and independent determinants for septum thickness, relative wall thickness and posterior wall thickness (parameters of left ventricular hypertrophy) were: age (p = 0.025; p = 0.010; p = 0.032, respectively) and 24 h-SBP (p < 0.001 in the three parameters). CONCLUSION BP variability estimated by 24 h-ABPM is not independently associated with echocardiographic parameters in diabetic-hypertensive patients.
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Affiliation(s)
- Daniela Massierer
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
| | - Liana Farias Leiria
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
| | - Mateus Dorneles Severo
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Priscila Dos Santos Ledur
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Alexandre Dalpiaz Becker
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Fernanda Mus Aguiar
- Universidade Federal de Ciências da Saúde de Porto Alegre, Rua Sarmento Leite, 245, 90050-170, Porto Alegre, RS, Brazil.
| | - Eliandra Lima
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Valéria Centeno Freitas
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil.
| | - Beatriz D Schaan
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Faculty of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, Porto Alegre, RS, Brazil.
| | - Miguel Gus
- Cardiology, Hospital de Clínicas de Porto Alegre, Rua Ramiro Barcelos 2350, sala 2061, 90035-003, Porto Alegre, RS, Brazil. .,Postgraduate Studies Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400 - 2° andar, Porto Alegre, RS, Brazil.
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16
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Differential impact of type-1 and type-2 diabetes on control of heart rate in mice. Auton Neurosci 2015; 194:17-25. [PMID: 26725752 DOI: 10.1016/j.autneu.2015.12.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 11/23/2015] [Accepted: 12/14/2015] [Indexed: 01/14/2023]
Abstract
AIMS Cardiac autonomic dysfunction is a serious complication of diabetes. One consequence is disruption of the normal beat-to-beat regulation of heart rate (HR), i.e. HR variability (HRV). However, our understanding of the disease process has been limited by inconsistent HR/HRV data from previous animal studies. We hypothesized that differences in the method of measurement, time of day, and level of stress account for the differing results across studies. Thus, our aim was to systematically assess HR and HRV in two common diabetic mouse models. METHODS ECG radiotelemetry devices were implanted into db/db (type-2 diabetic), STZ-treated db/+ (type-1 diabetic), and control db/+ mice (n=4 per group). HR and HRV were analyzed over 24 h and during treadmill testing. RESULTS 24 h analysis revealed that db/db mice had an altered pattern of circadian HR changes, and STZ-treated mice had reduced HR throughout. HRV measures linked to sympathetic control were reduced in db/db mice in the early morning and early afternoon, and partially reduced in STZ-treated mice. HR response to treadmill testing was blunted in both models. CONCLUSIONS It is important to consider both time of day and level of stress when assessing HR and HRV in diabetic mice. db/db mice may have altered circadian rhythm of sympathetic control of HR, whereas STZ-treated mice have a relative reduction. This study provides baseline data and a framework for HR analysis that may guide future investigations.
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17
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Thaung HPA, Baldi JC, Wang HY, Hughes G, Cook RF, Bussey CT, Sheard PW, Bahn A, Jones PP, Schwenke DO, Lamberts RR. Increased Efferent Cardiac Sympathetic Nerve Activity and Defective Intrinsic Heart Rate Regulation in Type 2 Diabetes. Diabetes 2015; 64:2944-56. [PMID: 25784543 DOI: 10.2337/db14-0955] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 03/09/2015] [Indexed: 11/13/2022]
Abstract
Elevated sympathetic nerve activity (SNA) coupled with dysregulated β-adrenoceptor (β-AR) signaling is postulated as a major driving force for cardiac dysfunction in patients with type 2 diabetes; however, cardiac SNA has never been assessed directly in diabetes. Our aim was to measure the sympathetic input to and the β-AR responsiveness of the heart in the type 2 diabetic heart. In vivo recording of SNA of the left efferent cardiac sympathetic branch of the stellate ganglion in Zucker diabetic fatty rats revealed an elevated resting cardiac SNA and doubled firing rate compared with nondiabetic rats. Ex vivo, in isolated denervated hearts, the intrinsic heart rate was markedly reduced. Contractile and relaxation responses to β-AR stimulation with dobutamine were compromised in externally paced diabetic hearts, but not in diabetic hearts allowed to regulate their own heart rate. Protein levels of left ventricular β1-AR and Gs (guanine nucleotide binding protein stimulatory) were reduced, whereas left ventricular and right atrial β2-AR and Gi (guanine nucleotide binding protein inhibitory regulatory) levels were increased. The elevated resting cardiac SNA in type 2 diabetes, combined with the reduced cardiac β-AR responsiveness, suggests that the maintenance of normal cardiovascular function requires elevated cardiac sympathetic input to compensate for changes in the intrinsic properties of the diabetic heart.
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Affiliation(s)
- H P Aye Thaung
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - J Chris Baldi
- Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Heng-Yu Wang
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Gillian Hughes
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Rosalind F Cook
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Carol T Bussey
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Phil W Sheard
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Andrew Bahn
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Peter P Jones
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Daryl O Schwenke
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
| | - Regis R Lamberts
- HeartOtago, Department of Physiology, Otago School of Medical Sciences, University of Otago, Dunedin, New Zealand
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18
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Wagner J, Lampert R, Tennen H, Feinn R. Exposure to Discrimination and Heart Rate Variability Reactivity to Acute Stress among Women with Diabetes. Stress Health 2015; 31:255-62. [PMID: 24194397 DOI: 10.1002/smi.2542] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 09/17/2013] [Accepted: 09/19/2013] [Indexed: 11/05/2022]
Abstract
Exposure to racial discrimination has been linked to physiological reactivity. This study investigated self-reported exposure to racial discrimination and parasympathetic [high-frequency heart rate variability (HF-HRV)] and sympathetic (norepinephrine and cortisol) activity at baseline and then again after acute laboratory stress. Lifetime exposure to racial discrimination was measured with the Schedule of Racist Events scale. Thirty-two women (16 Black and 16 White) with type 2 diabetes performed a public speaking stressor. Beat-to-beat intervals were recorded on electrocardiograph recorders, and HF-HRV was calculated using spectral analysis and natural log transformed. Norepinephrine and cortisol were measured in blood. Higher discrimination predicted lower stressor HF-HRV, even after controlling for baseline HF-HRV. When race, age, A1c and baseline systolic blood pressure were also controlled, racial discrimination remained a significant independent predictor of stressor HF-HRV. There was no association between lifetime discrimination and sympathetic markers. In conclusion, preliminary data suggest that among women with type 2 diabetes mellitus (T2DM), exposure to racial discrimination is adversely associated with parasympathetic, but not sympathetic, reactivity.
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Affiliation(s)
- Julie Wagner
- MC3910 Division of Behavioral Sciences and Community Health, University of Connecticut Health Center, Farmington, CT, USA
| | - Rachel Lampert
- Department of Cardiology, Yale University School of Medicine, New Haven, CT, USA
| | - Howard Tennen
- Howard Tennen, Department of Community Medicine, University of Connecticut Health Cente, Farmington, CT, USA
| | - Richard Feinn
- Quinnipiac University School of Medicine, Hamden, CT, USA
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Thaung HPA, Yao Y, Bussey CT, Hughes G, Jones PP, Bahn A, Sammut IA, Lamberts RR. Chronic bilateral renal denervation reduces cardiac hypertrophic remodelling but not β-adrenergic responsiveness in hypertensive type 1 diabetic rats. Exp Physiol 2015; 100:628-39. [DOI: 10.1113/ep085021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 04/13/2015] [Indexed: 11/08/2022]
Affiliation(s)
- H. P. Aye Thaung
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Yimin Yao
- Department of Pharmacology and Toxicology, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Carol T. Bussey
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Gillian Hughes
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Peter P. Jones
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Andrew Bahn
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Ivan A. Sammut
- Department of Pharmacology and Toxicology, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
| | - Regis R. Lamberts
- Department of Physiology - HeartOtago, Otago School of Medical Sciences; University of Otago; Dunedin New Zealand
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Balcıoğlu AS, Müderrisoğlu H. Diabetes and cardiac autonomic neuropathy: Clinical manifestations, cardiovascular consequences, diagnosis and treatment. World J Diabetes 2015; 6:80-91. [PMID: 25685280 PMCID: PMC4317320 DOI: 10.4239/wjd.v6.i1.80] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Revised: 09/24/2014] [Accepted: 12/01/2014] [Indexed: 02/05/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is a frequent chronic complication of diabetes mellitus with potentially life-threatening outcomes. CAN is caused by the impairment of the autonomic nerve fibers regulating heart rate, cardiac output, myocardial contractility, cardiac electrophysiology and blood vessel constriction and dilatation. It causes a wide range of cardiac disorders, including resting tachycardia, arrhythmias, intraoperative cardiovascular instability, asymptomatic myocardial ischemia and infarction and increased rate of mortality after myocardial infarction. Etiological factors associated with autonomic neuropathy include insufficient glycemic control, a longer period since the onset of diabetes, increased age, female sex and greater body mass index. The most commonly used methods for the diagnosis of CAN are based upon the assessment of heart rate variability (the physiological variation in the time interval between heartbeats), as it is one of the first findings in both clinically asymptomatic and symptomatic patients. Clinical symptoms associated with CAN generally occur late in the disease process and include early fatigue and exhaustion during exercise, orthostatic hypotension, dizziness, presyncope and syncope. Treatment is based on early diagnosis, life style changes, optimization of glycemic control and management of cardiovascular risk factors. Medical therapies, including aldose reductase inhibitors, angiotensin-converting enzyme inhibitors, prostoglandin analogs and alpha-lipoic acid, have been found to be effective in randomized controlled trials. The following article includes the epidemiology, clinical findings and cardiovascular consequences, diagnosis, and approaches to prevention and treatment of CAN.
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Abstract
In spite of new therapy options the life expectancy of patients with diabetes mellitus is clearly reduced compared to the average population. In addition to coronary heart disease and diabetic cardiomyopathy, cardiac autonomic neuropathy (CAN) is also a factor in patients with diabetes mellitus. The CAN is an impairment of cardiovascular control. A reduced variability of heart rate up to the point of a fixed heart rate are symptoms of CAN. In addition symptomatic hypotension, a reduced left ventricular ejection fraction, cardiac arrhythmia and sudden cardiac death are also signs of CAN. Prevalence rates of CAN increase with age and are approximately 38 % in patients 40-70 years old with diabetes mellitus type 1 and 44 % in patients with diabetes mellitus type 2. The disease is usually documented using miscellaneous cardiovascular autonomic tests so that therapy can be started as soon as possible.
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Hjortkær H, Jensen T, Kofoed K, Mogensen U, Køber L, Hilsted KL, Corinth H, Theilade S, Hilsted J. Nocturnal antihypertensive treatment in patients with type 1 diabetes with autonomic neuropathy and non-dipping of blood pressure during night time: protocol for a randomised, placebo-controlled, double-blind, two-way crossover study. BMJ Open 2014; 4:e006142. [PMID: 25293387 PMCID: PMC4187995 DOI: 10.1136/bmjopen-2014-006142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/15/2014] [Accepted: 09/16/2014] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Cardiac autonomic neuropathy (CAN) and elevated nocturnal blood pressure are independent risk factors for cardiovascular disease in patients with diabetes. Previously, associations between CAN, non-dipping of nocturnal blood pressure and coronary artery calcification have been demonstrated. The present protocol describes a trial to test the efficacy of bedtime dosing of the ACE inhibitor enalapril on night time blood pressure and left ventricular mass in patients with type 1 diabetes. MATERIALS AND METHODS In a randomised, double-blind, two-way cross-over study, 24 normoalbuminuric patients with type 1 diabetes with CAN will be treated for 12 weeks with either morning or bedtime dosing of 20 mg enalapril, followed by 12 weeks of switched treatment regimen. During each treatment period, two 24 h ambulatory blood pressure measurements will be performed and after each treatment period left ventricular mass will be determined by multisliced CT. Primary end points will be reduction in blood pressure and reduction in left ventricular mass. ETHICS AND DISSEMINATION The study has been approved by the Danish Medicines Agency, the Scientific-Ethical Committee of the Capital Region of Denmark and the Danish Data Protection Agency. An external monitoring committee (the Good Clinical Practice Unit at Copenhagen University Hospital) will oversee the study. The results of the study will be presented at national and international scientific meetings and publications will be submitted to peer-reviewed journals. TRIAL REGISTRATION NUMBER EudraCT (2012- 002136-90).
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Affiliation(s)
- Henrik Hjortkær
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tonny Jensen
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Kofoed
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ulrik Mogensen
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Karen Lisa Hilsted
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Helle Corinth
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Jannik Hilsted
- Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Balcioğlu AS, Çiçek D, Akinci S, Eldem HO, Bal UA, Okyay K, Müderrisoğlu H. Arrhythmogenic evidence for epicardial adipose tissue: heart rate variability and turbulence are influenced by epicardial fat thickness. Pacing Clin Electrophysiol 2014; 38:99-106. [PMID: 25224491 DOI: 10.1111/pace.12512] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Revised: 07/11/2014] [Accepted: 07/29/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Epicardial adipose tissue (EAT) is a local source of various hormones, cytokines, and vasoactive substances affecting the myocardium. EAT contains abundant ganglionic plexi that interact with the autonomic nervous system. Evidence of the association between EAT and arrhythmia is limited, with the exception of atrial fibrillation. This study aimed to investigate the relation between EAT and cardiac autonomic function using heart rate variability (HRV) and heart rate turbulence (HRT) parameters. METHODS All subjects underwent a 24-hour Holter recording to assess HRV and HRT parameters and a transthoracic echocardiography to measure EAT thickness. Patients were divided into two groups according to the median EAT thickness (3.9 mm). The higher EAT group consisted of 111 patients with a >3.9-mm thickness and the lower EAT group 113 patients with a ≤ 3.9-mm EAT thickness. RESULTS HRV and HRT parameters were significantly influenced in the higher EAT group. Moreover, we observed significant correlations between EAT thickness and Holter findings (standard deviation of all NN intervals [SDNN]: r = -0.462, P < 0.001; SDNN index: r = -0.349, P < 0.001; standard deviation of the average NN intervals: r = -0.465, P < 0.001; root mean square of successive differences: r = -0.251, P < 0.001; pNN50: r = -0.354, P < 0.001; turbulence onset: r = 0.172, P = 0.010; turbulence slope: r = -0.279, P < 0.001, HRT category: r = 0.169, P = 0.011). In multivariate regression analysis, EAT thickness was independently associated with all measures of HRV and HRT, with the exception of turbulence onset. CONCLUSIONS Sympathovagal imbalance, detected by HRV and HRT parameters, is related to EAT thickness. As sympathovagal imbalance is a predictor of arrhythmic events, EAT may play an important arrhythmogenic role not limited to atrial fibrillation.
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Affiliation(s)
- Akif Serhat Balcioğlu
- Department of Cardiology, Medical and Research Center of Alanya, Başkent University, Antalya, Turkey
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24
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Ono K, Yamasue K, Tochikubo O, Terauchi Y, Mizushima S. Lifestyle monitoring with the use of an earphone-type thermometer, an ambulatory blood pressure monitoring and a new wristwatch-type pulsimeter with accelerometer. Clin Exp Hypertens 2014; 36:97-102. [PMID: 24625336 DOI: 10.3109/10641963.2014.892120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
We investigated the relationship among 24-h blood pressure (BP), pulse rate (PR) and core temperature by using an ambulatory BP monitoring, a new wristwatch-type pulsimeter with accelerometer (WPA) and an ear thermometer simultaneously. Our results suggest that the ear temperature which reflects the core body temperature was lowest at base PR during sleep and 75% of normotensives and 54% of subjects without hypertensive medication had a significant correlation between BP and PR. Diabetic subjects showed a significantly higher PR during sleep than non-diabetic subjects. Three types of equipments, especially a new WPA, are expected to be useful for daily lifestyle monitoring to evaluate risk of complications of hypertension and diabetes.
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Affiliation(s)
- Kanako Ono
- Graduate School of Medicine, Epidemiology and Public Health and
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25
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Dimitropoulos G, Tahrani AA, Stevens MJ. Cardiac autonomic neuropathy in patients with diabetes mellitus. World J Diabetes 2014; 5:17-39. [PMID: 24567799 PMCID: PMC3932425 DOI: 10.4239/wjd.v5.i1.17] [Citation(s) in RCA: 177] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 12/02/2013] [Accepted: 12/12/2013] [Indexed: 02/05/2023] Open
Abstract
Cardiac autonomic neuropathy (CAN) is an often overlooked and common complication of diabetes mellitus. CAN is associated with increased cardiovascular morbidity and mortality. The pathogenesis of CAN is complex and involves a cascade of pathways activated by hyperglycaemia resulting in neuronal ischaemia and cellular death. In addition, autoimmune and genetic factors are involved in the development of CAN. CAN might be subclinical for several years until the patient develops resting tachycardia, exercise intolerance, postural hypotension, cardiac dysfunction and diabetic cardiomyopathy. During its sub-clinical phase, heart rate variability that is influenced by the balance between parasympathetic and sympathetic tones can help in detecting CAN before the disease is symptomatic. Newer imaging techniques (such as scintigraphy) have allowed earlier detection of CAN in the pre-clinical phase and allowed better assessment of the sympathetic nervous system. One of the main difficulties in CAN research is the lack of a universally accepted definition of CAN; however, the Toronto Consensus Panel on Diabetic Neuropathy has recently issued guidance for the diagnosis and staging of CAN, and also proposed screening for CAN in patients with diabetes mellitus. A major challenge, however, is the lack of specific treatment to slow the progression or prevent the development of CAN. Lifestyle changes, improved metabolic control might prevent or slow the progression of CAN. Reversal will require combination of these treatments with new targeted therapeutic approaches. The aim of this article is to review the latest evidence regarding the epidemiology, pathogenesis, manifestations, diagnosis and treatment for CAN.
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26
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Frontoni S, Di Bartolo P, Avogaro A, Bosi E, Paolisso G, Ceriello A. Glucose variability: An emerging target for the treatment of diabetes mellitus. Diabetes Res Clin Pract 2013; 102:86-95. [PMID: 24128999 DOI: 10.1016/j.diabres.2013.09.007] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2013] [Revised: 05/19/2013] [Accepted: 09/09/2013] [Indexed: 02/08/2023]
Abstract
Alterations in glucose metabolism in individuals with diabetes have been considered for many years, as they appear at first glance, i.e., simply as hyperglycemia, and its surrogate marker, glycated hemoglobin (HbA1c), used both to estimate the risk of developing diabetic complications and to define the targets and measure the efficacy of diabetes treatments. However, over time diabetes-related glycemic alterations have been considered in more complex terms, by attempting to identify the role of fasting glycemia, postprandial glycemia and hypoglycemia in the overall assessment of the disease. This set of evaluations has led to the concept of glucose variability. Although intuitively easy to understand, it cannot be equally simply translated into terms of definition, measuring, prognostic and therapeutic impact. The literature available on glucose variability is extensive yet confused, with the only common element being the need to find out more on the subject. The purpose of this manuscript is not only to review the most recent evidence on glucose variability, but also to help the reader to better understand the available measurement options, and how the various definitions can differently be related with the development of diabetic complications. Finally, we provide how new and old drugs can impact on glucose variability.
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Affiliation(s)
- Simona Frontoni
- Dipartimento di Medicina dei Sistemi, Università degli Studi di Roma "Tor Vergata", Italy
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27
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Kanaoka T, Tamura K, Wakui H, Ohsawa M, Azushima K, Uneda K, Kobayashi R, Fujikawa T, Tsurumi-Ikeya Y, Maeda A, Yanagi M, Toya Y, Umemura S. L/N-type calcium channel blocker cilnidipine added to renin-angiotensin inhibition improves ambulatory blood pressure profile and suppresses cardiac hypertrophy in hypertension with chronic kidney disease. Int J Mol Sci 2013; 14:16866-81. [PMID: 23959116 PMCID: PMC3759940 DOI: 10.3390/ijms140816866] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 08/09/2013] [Accepted: 08/12/2013] [Indexed: 01/22/2023] Open
Abstract
Ambulatory blood pressure (BP) and heart rate (HR) profile are proposed to be related to renal deterioration and cardiovascular complication in hypertension and chronic kidney disease (CKD). In this study, we examined the beneficial effects cilnidipine, a unique L/N-type calcium channel blocker (CCB), in addition to renin-angiotensin system inhibitors, on ambulatory BP and HR profile, as well as cardiorenal function in hypertensive CKD patients. Forty-five patients were randomly assigned to the cilnidipine replacement group (n = 21) or the control CCBs group (n = 24) during a 24-week active treatment period. Although clinical BP values were similar in the cilnidipine and control CCBs groups after the treatment period, the results of ambulatory BP monitoring showed that the 24-h and daytime systolic BP levels in the cilnidipine group were significantly lower compared with the control group after the study. Furthermore, the left ventricular mass index (LVMI) was significantly decreased in the cilnidipine group compared to the control group after the study (LVMI, 135.3 ± 26.4 versus 181.2 ± 88.4, p = 0.031), with a significant difference in the changes in the LVMI between the cilnidipine and control groups (change in LVMI, −12.4 ± 23.7 versus 26.2 ± 64.4, p = 0.007). These results indicate that cilnidipine is beneficial for the suppression of pathological cardiac remodeling, at least partly, via a superior improving effect on ambulatory BP profile compared with control CCBs in hypertensive CKD patients.
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Affiliation(s)
| | - Kouichi Tamura
- Author to whom correspondence should be addressed; E-Mail: ; Tel.: +81-45-787-2635 (ext. 6326); Fax: +81-45-701-3738
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28
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Addition of aliskiren to Angiotensin receptor blocker improves ambulatory blood pressure profile and cardiorenal function better than addition of benazepril in chronic kidney disease. Int J Mol Sci 2013; 14:15361-75. [PMID: 23887656 PMCID: PMC3759864 DOI: 10.3390/ijms140815361] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 06/25/2013] [Accepted: 06/28/2013] [Indexed: 01/08/2023] Open
Abstract
An altered ambulatory blood pressure (BP) and heart rate (HR) profile is related to chronic kidney disease (CKD) and cardiorenal syndrome. In this study, we examined the effects of aliskiren, when added to angiotensin II type 1 receptor blockers, on ambulatory BP and cardiorenal function in CKD. Thirty-six hypertensive CKD patients were randomly assigned to the aliskiren add-on group (n = 18) or the benazepril add-on group (n = 18). Ambulatory BP and cardiorenal function parameters were measured at baseline and 24 weeks after treatment. Compared with the benazepril group, nighttime systolic BP variability in the aliskiren group was lower after treatment. Albuminuria was decreased in the aliskiren group, but not in the benazepril group. In addition, left ventricular mass index (LVMI) was significantly lower in the aliskiren group than in the benazepril group after treatment. In the aliskiren group, multivariate linear regression analysis showed an association between changes in albuminuria and changes in nighttime systolic BP. Furthermore, there were associations between changes in LVMI and changes in daytime HR variability, as well as between changes in LVMI and changes in plasma aldosterone concentration. These results suggest that aliskiren add-on therapy may be beneficial for suppression of renal deterioration and pathological cardiac remodeling through an improvement that is effected in ambulatory BP and HR profiles.
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Hermida RC, Smolensky MH, Ayala DE, Portaluppi F, Crespo JJ, Fabbian F, Haus E, Manfredini R, Mojón A, Moyá A, Piñeiro L, Ríos MT, Otero A, Balan H, Fernández JR. 2013 Ambulatory Blood Pressure Monitoring Recommendations for the Diagnosis of Adult Hypertension, Assessment of Cardiovascular and other Hypertension-associated Risk, and Attainment of Therapeutic Goals. Chronobiol Int 2013; 30:355-410. [DOI: 10.3109/07420528.2013.750490] [Citation(s) in RCA: 137] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Karayannis G, Giamouzis G, Cokkinos DV, Skoularigis J, Triposkiadis F. Diabetic cardiovascular autonomic neuropathy: clinical implications. Expert Rev Cardiovasc Ther 2013; 10:747-65. [PMID: 22894631 DOI: 10.1586/erc.12.53] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic cardiovascular autonomic neuropathy (DCAN), the impairment of the autonomic balance of the cardiovascular system in the setting of diabetes mellitus (DM), is frequently observed in both Type 1 and 2 DM, has detrimental effects on the quality of life and portends increased mortality. Clinical manifestations include: resting heart rate disorders, exercise intolerance, intraoperative cardiovascular lability, orthostatic alterations in heart rate and blood pressure, QT-interval prolongation, abnormal diurnal and nocturnal blood pressure variation, silent myocardial ischemia and diabetic cardiomyopathy. Clinical tests for autonomic nervous system evaluation, heart rate variability analysis, autonomic innervation imaging techniques, microneurography and baroreflex analysis are the main diagnostic tools for DCAN detection. Aldose reductase inhibitors and antioxidants may be helpful in DCAN therapy, but a regular, more generalized and multifactorial approach should be adopted with inclusion of lifestyle modifications, strict glycemic control and treatment of concomitant traditional cardiovascular risk factors, in order to achieve the best therapeutic results. In the present review, the authors provide aspects of DCAN pathophysiology, clinical presentation, diagnosis and an algorithm regarding the evaluation and management of DCAN in DM patients.
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Abstract
Heart rate variability (HRV) provides indirect insight into autonomic nervous system tone, and has a well-established role as a marker of cardiovascular risk. Recent decades brought an increasing interest in HRV assessment as a diagnostic tool in detection of autonomic impairment, and prediction of prognosis in several neurological disorders. Both bedside analysis of simple markers of HRV, as well as more sophisticated HRV analyses including time, frequency domain and nonlinear analysis have been proven to detect early autonomic involvement in several neurological disorders. Furthermore, altered HRV parameters were shown to be related with cardiovascular risk, including sudden cardiac risk, in patients with neurological diseases. This chapter aims to review clinical and prognostic application of HRV analysis in diabetes, stroke, multiple sclerosis, muscular dystrophies, Parkinson's disease and epilepsy.
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Affiliation(s)
- Iwona Cygankiewicz
- Department of Electrocardiology, Medical University of Lodz, Lodz, Poland.
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32
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Froy O. Circadian rhythms and obesity in mammals. ISRN OBESITY 2012; 2012:437198. [PMID: 24527263 PMCID: PMC3914271 DOI: 10.5402/2012/437198] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/16/2012] [Accepted: 11/11/2012] [Indexed: 02/02/2023]
Abstract
Obesity has become a serious public health problem and a major risk factor for the development of illnesses, such as insulin resistance and hypertension. Attempts to understand the causes of obesity and develop new therapeutic strategies have mostly focused on caloric intake and energy expenditure. Recent studies have shown that the circadian clock controls energy homeostasis by regulating the circadian expression and/or activity of enzymes, hormones, and transport systems involved in metabolism. Moreover, disruption of circadian rhythms leads to obesity and metabolic disorders. Therefore, it is plausible that resetting of the circadian clock can be used as a new approach to attenuate obesity. Feeding regimens, such as restricted feeding (RF), calorie restriction (CR), and intermittent fasting (IF), provide a time cue and reset the circadian clock and lead to better health. In contrast, high-fat (HF) diet leads to disrupted circadian expression of metabolic factors and obesity. This paper focuses on circadian rhythms and their link to obesity.
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Affiliation(s)
- Oren Froy
- Institute of Biochemistry, Food Science and Nutrition, Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, P.O. Box 12, 76100 Rehovot, Israel
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The angiotensin II type 1 receptor blocker olmesartan preferentially improves nocturnal hypertension and proteinuria in chronic kidney disease. Hypertens Res 2012; 36:262-9. [PMID: 23154587 DOI: 10.1038/hr.2012.184] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Accumulated evidence suggests that an altered ambulatory blood pressure (BP) profile, particularly elevated nighttime BP, reflects target organ injury and is a better predictor of further cardiorenal risk than the clinic BP or daytime BP in hypertensive patients complicated by chronic kidney disease (CKD). In this study, we examined the beneficial effects of olmesartan, an angiotensin II type 1 receptor blocker (ARB), on ambulatory BP profiles and renal function in hypertensive CKD patients. Forty-six patients were randomly assigned to the olmesartan add-on group (n=23) or the non-ARB group (n=23). At baseline and after the 16-week treatment period, ambulatory BP monitoring was performed and renal function parameter measurements were collected. Although the baseline clinic BP levels and the after-treatment/baseline (A/B) ratios of clinic BP levels were similar in the olmesartan add-on and non-ARB groups, the A/B ratios of ambulatory 24-h and nighttime BP levels in the olmesartan add-on group were significantly lower. Furthermore, the A/B ratios of urinary protein, albumin and type IV collagen excretion in the olmesartan add-on group were significantly lower than those in the non-ARB group (urinary protein excretion, 0.72±0.41 vs. 1.45±1.48, P=0.030; urinary albumin excretion, 0.73±0.37 vs. 1.50±1.37, P=0.005; urinary type IV collagen excretion, 0.87±0.42 vs. 1.48±0.87, P=0.014) despite comparable A/B ratios for the estimated glomerular filtration rate in the two groups. These results indicate that in hypertensive patients with CKD, olmesartan add-on therapy improves the ambulatory BP profile via a preferential reduction in nighttime BP with concomitant renal injury inhibition.
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Pop-Busui R. What do we know and we do not know about cardiovascular autonomic neuropathy in diabetes. J Cardiovasc Transl Res 2012; 5:463-78. [PMID: 22644723 DOI: 10.1007/s12265-012-9367-6] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 04/12/2012] [Indexed: 12/16/2022]
Abstract
Cardiovascular autonomic neuropathy (CAN) in diabetes is generally overlooked in practice, although awareness of its serious consequences is emerging. Challenges in understanding the complex, dynamic changes in the modulation of the sympathetic/parasympathetic systems' tone and their interactions with physiologic mechanisms regulating the control of heart rate, blood pressure, and other cardiovascular functions in the presence of acute hyper-or-hypoglycemic stress, other stressors or medication, and challenges with sensitive evaluations have contributed to lower CAN visibility compared with other diabetes complications. Yet, CAN is a significant cause of morbidity and mortality, due to a high-risk of cardiac arrhythmias, silent myocardial ischemia and sudden death. While striving for aggressive risk factor control in diabetes practice seemed intuitive, recent reports of major clinical trials undermine established thinking concerning glycemic control and cardiovascular risk. This review covers current understanding and gaps in that understanding of the clinical implications of CAN and prevention and treatment of CAN.
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Affiliation(s)
- Rodica Pop-Busui
- Division of Metabolism, Endocrinology and Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA.
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35
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Kanaoka T, Tamura K, Ohsawa M, Yanagi M, Haku S, Wakui H, Maeda A, Dejima T, Azushima K, Mitsuhashi H, Okano Y, Fujikawa T, Toya Y, Mizushima S, Tochikubo O, Umemura S. Relationship of ambulatory blood pressure and the heart rate profile with renal function parameters in hypertensive patients with chronic kidney disease. Clin Exp Hypertens 2012; 34:264-9. [PMID: 22578052 DOI: 10.3109/10641963.2012.681082] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Strict blood pressure (BP) control is reportedly important for the management of hypertensive patients with chronic kidney disease (CKD). The purpose of this cross-sectional study was to examine whether the variables of ambulatory BP and the heart rate (HR) profile, central hemodynamics, and arterial stiffness were closely related to the renal function parameters (urine albumin excretion rate [UACR] and estimated glomerular filtration rate [eGFR]) observed in 25 consecutive hospitalized hypertensive patients with CKD. There were significant positive relationships between UACR and 24-hour, daytime, and nighttime ambulatory systolic BP. In addition, there were significant negative relationships between UACR and 24-hour and daytime HR variability. The circulating B-type natriuretic peptide level and hemoglobin A1c were also positively related to UACR. With respect to eGFR, although the 24-hour and nighttime HR variability were positively associated with eGFR, the circulating pentosidine and nighttime HR had a negative relationship with eGFR. On the other hand, central hemodynamics and arterial stiffness did not exhibit any significant association with renal function parameters. These results indicate that ambulatory BP and the HR profile are closely modulated by renal function deterioration. Further studies are needed to investigate the causal relationship between ambulatory BP and the HR profile and renal function parameters in hypertensive patients with CKD.
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Affiliation(s)
- Tomohiko Kanaoka
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Abstract
Diabetic autonomic neuropathies are a heterogeneous and progressive disease entity and commonly complicate both type 1 and type 2 diabetes mellitus. Although the aetiology is not entirely understood, hyperglycaemia, insulin deficiency, metabolic derangements and potentially autoimmune mechanisms are thought to play an important role. A subgroup of diabetic autonomic neuropathy, cardiovascular autonomic neuropathy (CAN), is one of the most common diabetes-associated complications and is ultimately clinically important because of its correlation with increased mortality. The natural history of CAN is unclear, but is thought to progress from a subclinical stage characterized by impaired baroreflex sensitivity and abnormalities of spectral analysis of heart rate variability to a clinically apparent stage with diverse and disabling symptoms. Early diagnosis of CAN, using spectral analysis of heart rate variability or scintigraphic imaging techniques, might enable identification of patients at highest risk for the development of clinical CAN and, thereby, enable the targeting of intensive therapeutic approaches. This Review discusses methods for diagnosis, epidemiology, natural history and potential causes and consequences of CAN.
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Affiliation(s)
- Michael Kuehl
- Cardiovascular Research Department, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
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37
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Hsiao JY, Tien KJ, Hsiao CT, Weng HH, Chung TC, Hsieh MC. The relationship between diabetic autonomic neuropathy and diabetic risk factors in a Taiwanese population. J Int Med Res 2012; 39:1155-62. [PMID: 21986117 DOI: 10.1177/147323001103900403] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
This study looked at spectral analysis of heart rate variability (HRV) between patients with type 2 diabetes mellitus (DM) and healthy controls. The association between diabetic autonomic neuropathy (DAN) with HRV parameter changes and DM risk factors (including nephropathy) was investigated. HRV parameters were compared between 271 patients with DM and 160 controls. A statistically significant difference was found between the two groups for each parameter. Patients with DM were then divided into three groups by the levels of individual risk factors: body mass index, total cholesterol, 2-h postprandial plasma glucose concentration, glycosylated haemoglobin, duration of DM and the albumin-creatinine ratio. HRV parameters decreased significantly in patients with DM as the risk factor level progressed. This study identified previously known and new potential risk factors for the development of DAN, which may be important for the development of risk reduction strategies.
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Affiliation(s)
- J-Y Hsiao
- Division of Endocrinology and Metabolism, Ture Generation Hospital, Kaohsiung, Taiwan
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Spallone V, Ziegler D, Freeman R, Bernardi L, Frontoni S, Pop-Busui R, Stevens M, Kempler P, Hilsted J, Tesfaye S, Low P, Valensi P. Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management. Diabetes Metab Res Rev 2011; 27:639-53. [PMID: 21695768 DOI: 10.1002/dmrr.1239] [Citation(s) in RCA: 546] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 05/10/2011] [Indexed: 12/14/2022]
Abstract
The Cardiovascular Autonomic Neuropathy (CAN) Subcommittee of the Toronto Consensus Panel on Diabetic Neuropathy worked to update CAN guidelines, with regard to epidemiology, clinical impact, diagnosis, usefulness of CAN testing, and management. CAN is the impairment of cardiovascular autonomic control in the setting of diabetes after exclusion of other causes. The prevalence of confirmed CAN is around 20%, and increases up to 65% with age and diabetes duration. Established risk factors for CAN are glycaemic control in type 1 and a combination of hypertension, dyslipidaemia, obesity, and glycaemic control in type 2 diabetes. CAN is a risk marker of mortality and cardiovascular morbidity, and possibly a progression promoter of diabetic nephropathy. Criteria for CAN diagnosis and staging are: (1) one abnormal cardiovagal test result identifies possible or early CAN; (2) at least two abnormal cardiovagal test results are required for definite or confirmed CAN; and (3) the presence of orthostatic hypotension in addition to abnormal heart rate test results identifies severe or advanced CAN. Progressive stages of CAN are associated with increasingly worse prognosis. CAN assessment is relevant in clinical practice for (1) diagnosis of CAN clinical forms, (2) detection and tailored treatment of CAN clinical correlates (e.g. tachycardia, orthostatic hypotension, non-dipping, QT interval prolongation), (3) risk stratification for diabetic complications and cardiovascular morbidity and mortality, and (4) modulation of targets of diabetes therapy. Evidence on the cost-effectiveness of CAN testing is lacking. Apart from the preventive role of intensive glycaemic control in type 1 diabetes, recommendations cannot be made for most therapeutic approaches to CAN.
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Affiliation(s)
- Vincenza Spallone
- Department of Internal Medicine, University of Tor Vergata, Rome, Italy.
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Tamura K, Azushima K, Umemura S. Day-by-day home-measured blood pressure variability: another important factor in hypertension with diabetic nephropathy? Hypertens Res 2011; 34:1249-50. [PMID: 21866109 DOI: 10.1038/hr.2011.149] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan.
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Kanaoka T, Tamura K, Moriya T, Tanaka K, Konno Y, Kondoh S, Toyoda M, Umezono T, Fujikawa T, Ohsawa M, Dejima T, Maeda A, Wakui H, Haku S, Yanagi M, Mitsuhashi H, Ozawa M, Okano Y, Ogawa N, Yamakawa T, Mizushima S, Suzuki D, Umemura S. Effects of Multiple Factorial Intervention on Ambulatory BP Profile and Renal Function in Hypertensive Type 2 Diabetic Patients with Overt Nephropathy – A Pilot Study. Clin Exp Hypertens 2011; 33:255-63. [DOI: 10.3109/10641963.2011.583971] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Abstract
Mammals have developed an endogenous circadian clock located in the SCN (suprachiasmatic nuclei) of the anterior hypothalamus that responds to the environmental light–dark cycle. Human homoeostatic systems have adapted to daily changes in a way that the body anticipates the sleep and activity periods. Similar clocks have been found in peripheral tissues, such as the liver, intestine and adipose tissue. Recently it has been found that the circadian clock regulates cellular and physiological functions in addition to the expression and/or activity of enzymes and hormones involved in metabolism. In turn, key metabolic enzymes and transcription activators interact with and affect the core clock mechanism. Animals with mutations in clock genes that disrupt cellular rhythmicity have provided evidence to the relationship between the circadian clock and metabolic homoeostasis. The present review will summarize recent findings concerning the relationship between metabolism and circadian rhythms.
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Cabezas-Cerrato J, Hermida RC, Cabezas-Agrícola JM, Ayala DE. Cardiac Autonomic Neuropathy, Estimated Cardiovascular Risk, and Circadian Blood Pressure Pattern in Diabetes Mellitus. Chronobiol Int 2010; 26:942-57. [DOI: 10.1080/07420520903044448] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Eguchi K, Schwartz JE, Pickering TG, Hoshide S, Ishikawa J, Shimada K, Kario K. Increased heart rate variability during sleep is a predictor for future cardiovascular events in patients with type 2 diabetes. Hypertens Res 2010; 33:737-42. [PMID: 20431592 DOI: 10.1038/hr.2010.61] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
We aimed this study to test the hypotheses that heart rate (HR) variability, evaluated by ambulatory blood pressure monitoring (ABPM), predicts risk of incident cardiovascular disease (CVD) in patients with type 2 diabetes (T2DM). ABPM was performed in 200 normotensive or hypertensive subjects with T2DM and 257 hypertensive subjects without diabetes (the mean age: 66.9+/-9.2 years; 38% were male). All subjects were untreated at the time of ABPM, and were followed for 67+/-27 months. Various measures of HR variability-standard deviation (s.d.) of HR, the root-mean-square of successive differences (RMSSD) of HR, systolic blood pressure (SBP)-HR relationships evaluated by slope and coefficients of correlation between SBP and HR-were used for the analyses. Cox proportional hazard models were used to estimate hazard ratios and 95% confidence intervals, after controlling for age, sex, body mass index, serum creatinine and 24-h SBP. During follow-up, there were 34 cardiovascular events. Awake HR variability in diabetics was smaller than non-diabetics, but sleep HR variability was similar between the groups. In multivariable analyses, increased sleep HR variability evaluated by s.d. and RMSSD of sleep HR, and slope and correlation coefficient of SBP-HR each was independently associated with the increased risk of CVD in T2DM. For non-diabetics, decreased slope of 24 h SBP-HR, and decreased correlation of 24 h SBP-HR were associated with increased risk of CVD. In conclusion, increased HR variability during sleep was a predictor for incident CVD in T2DM, but not in non-diabetics. Increased HR variability at night would reflect pathophysiological mechanism of T2DM.
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Affiliation(s)
- Kazuo Eguchi
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Tochigi, Japan.
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Affiliation(s)
- Rodica Pop-Busui
- Department of Internal Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan, Ann Arbor, Michigan, USA.
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Abstract
Obesity has become a serious public health problem and a major risk factor for the development of illnesses, such as insulin resistance and hypertension. Human homeostatic systems have adapted to daily changes in light and dark in a way that the body anticipates the sleep and activity periods. Mammals have developed an endogenous circadian clock located in the suprachiasmatic nuclei of the anterior hypothalamus that responds to the environmental light-dark cycle. Similar clocks have been found in peripheral tissues, such as the liver, intestine, and adipose tissue, regulating cellular and physiological functions. The circadian clock has been reported to regulate metabolism and energy homeostasis in the liver and other peripheral tissues. This is achieved by mediating the expression and/or activity of certain metabolic enzymes and transport systems. In return, key metabolic enzymes and transcription activators interact with and affect the core clock mechanism. In addition, the core clock mechanism has been shown to be linked with lipogenic and adipogenic pathways. Animals with mutations in clock genes that disrupt cellular rhythmicity have provided evidence for the relationship between the circadian clock and metabolic homeostasis. In addition, clinical studies in shift workers and obese patients accentuate the link between the circadian clock and metabolism. This review will focus on the interconnection between the circadian clock and metabolism, with implications for obesity and how the circadian clock is influenced by hormones, nutrients, and timed meals.
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Affiliation(s)
- Oren Froy
- Institute of Biochemistry, Food Science, and Nutrition, Robert H. Smith Faculty of Agriculture, Food and Environment, The Hebrew University of Jerusalem, Rehovot, Israel.
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Tofé Povedano S, García De La Villa B. 24-hour and nighttime blood pressures in type 2 diabetic hypertensive patients following morning or evening administration of olmesartan. J Clin Hypertens (Greenwich) 2010; 11:426-31. [PMID: 19695030 DOI: 10.1111/j.1751-7176.2009.00152.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Ambulatory blood pressure monitoring (ABPM) allows determining of the nocturnal blood pressure fall (NBPF). An NBPF below 10% (nondipper pattern) has been related to increased cardiovascular risk, and it is a common finding in type 2 diabetic hypertensive patients. The authors evaluated the impact on 24-hour blood pressure, NBPF, and albuminuria of olmesartan 40 mg, administered in a morning- vs a nocturnal-based dosing scheme, in type 2 diabetic patients with newly diagnosed hypertension. Using a crossover design, 40 patients (42.1% men) received olmesartan 40 mg once daily at wake up or bedtime for 8 weeks. Patients underwent 24-hour ABPM at baseline and at weeks 8 and 16, and albumin to creatinine ratio was measured at baseline and 8 weeks. Night systolic blood pressure (BP) (P=.007) and mean BP (P=.012) were significantly reduced following the bedtime dose, compared with morning dosing. Night BP fall (%) was significantly reduced by bedtime dosing, compared with morning dosing (P=.0001). No differences were seen for urinary albumin excretion between both arms at week 8. Without affecting 24-hour BP control, night dosing of olmesartan increases nocturnal BP fall significantly more than conventional morning dosing, increasing the number of dipper diabetic hypertensive patients.
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Masuda SI, Tamura K, Wakui H, Kanaoka T, Ohsawa M, Maeda A, Dejima T, Yanagi M, Azuma K, Umemura S. Effects of angiotensin II type 1 receptor blocker on ambulatory blood pressure variability in hypertensive patients with overt diabetic nephropathy. Hypertens Res 2009; 32:950-5. [PMID: 19713965 DOI: 10.1038/hr.2009.131] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Previous studies have shown increases in ambulatory short-term blood pressure (BP) variability to be related to cardiovascular disease. In this study, we examined whether the angiotensin II type 1 receptor blocker (ARB) would improve ambulatory short-term BP variability in hypertensive patients with diabetic nephropathy. A total of 30 patients with type II diabetes, along with hypertension and overt nephropathy, were enrolled in this randomized, two-period, crossover trial of 12 weeks of treatment with losartan (50 mg daily) and telmisartan (40 mg daily). At baseline and at the end of each treatment period, 24-h ambulatory BP monitoring with power spectral analysis of heart rate and measurements of proteinuria, estimated glomerular filtration rate and brachial-ankle pulse wave velocity (baPWV) were performed. After 12 weeks of treatment, 24-h, daytime and nighttime short-term BP variability, assessed on the basis of the coefficient of variation of ambulatory BP, was significantly decreased by telmisartan. Both losartan and telmisartan reduced urinary protein excretion and baPWV. However, compared with losartan, telmisartan significantly decreased urinary protein excretion, baPWV and low-frequency (LF)-to-high-frequency (HF) ratio, an index of sympathovagal balance. Multiple regression analysis showed significant correlations between urinary protein excretion and baPWV, 24-h LF-to-HF ratio, nighttime systolic BP and 24-h short-term systolic BP variability. These results suggest that ARB, particularly telmisartan, is effective in reducing proteinuria in hypertensive patients with overt diabetic nephropathy, partly through inhibitory effects on ambulatory short-term BP variability and sympathetic nerve activity, in addition to its longer duration of action on nighttime BP reduction.
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Affiliation(s)
- Shin-ichiro Masuda
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Ozawa M, Tamura K, Okano Y, Matsushita K, Yanagi M, Tsurumi-Ikeya Y, Oshikawa J, Hashimoto T, Masuda S, Wakui H, Shigenaga AI, Azuma K, Ishigami T, Toya Y, Ishikawa T, Umemura S. Identification of an Increased Short-Term Blood Pressure Variability on Ambulatory Blood Pressure Monitoring as a Coronary Risk Factor in Diabetic Hypertensives. Clin Exp Hypertens 2009; 31:259-70. [DOI: 10.1080/10641960902822518] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Monteagudo PT, Moisés VA, Kohlmann O, Ribeiro AB, Lima VC, Zanella MT. Influence of autonomic neuropathy upon left ventricular dysfunction in insulin-dependent diabetic patients. Clin Cardiol 2009; 23:371-5. [PMID: 10803447 PMCID: PMC6655188 DOI: 10.1002/clc.4960230513] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Diabetic cardiomyopathy is a well-defined complication of diabetes that occurs in the absence of ischemic, vascular, and hypertensive disease. HYPOTHESIS The study was undertaken to test the relationship among autonomic neuropathy (AN), 24-h blood pressure (BP) profile, and left ventricular function. METHODS Nineteen type-1 diabetic patients underwent autonomic tests and echocardiographic examination. Patients were divided according to the presence (AN+) or absence (AN-) of AN. RESULTS In the AN+ group (n = 8), the E/A ratio at echo was lower than in the AN- group (n = 11) (1.1 +/- 0.3 vs. 1.6 +/- 0.3; p < 0.005). Systolic and diastolic BP reductions during sleep were smaller in the AN+ than in the AN- group (6.6 +/- 6.6 vs. 13.0 +/- 4.3%; p < 0.03 for systolic and 12.8 +/- 6.8 vs. 20.0 +/- 4.0% for diastolic BP reduction; p < 0.03, respectively). Considering all patients, the E/A ratio correlated inversely with awake diastolic BP (r - 0.63; p = 0.005); sleep systolic BP (r - 0.48; p = 0.04), and sleep diastolic BP (r - 0.67; p = 0.002). The AN correlated with diastolic interventricular septum thickness (r 0.57; p = 0.01), sleep systolic BP (r 0.45; p = 0.05), sleep diastolic BP (r 0.54; p = 0.02), and correlated inversely with systolic and diastolic sleep BP reduction (r - 0.49; p = 0.03 and r - 0.67; p = 0.002, respectively). Finally, E/A ratio and AN score correlated between themselves (r - 0.6; p = 0.005). CONCLUSION Our results suggest that left ventricular diastolic dysfunction may be detected very early in type-1 diabetic patients with AN. Parasympathetic lesion and nocturnal elevations in BP could be the link between AN and diastolic ventricular dysfunction.
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Affiliation(s)
- P T Monteagudo
- Department of Medicine, Escola Paulista de Medicina, UNIFESP, São Paulo, Brazil
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