Silent ischaemia in diabetic men with autonomic neuropathy.

O’Sullivan, John; Conroy, R.; MacDonald, Karen; McKenna, T. J.; Maurer, B.

doi:10.1136/hrt.66.4.313

Cited by 52 publications

(26 citation statements)

References 13 publications

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“…In NIDDM patients the presence of autonomic neuropathy (AN) and reduced heart rate variability (HRV) have both been linked with a poor prognosis [4]. AN has also been associated with the presence of symptomatic CAD [5] and silent myocardial ischemia [6,7], which is a marker of CAD. tn IDDM patients the presence and degree of albuminuria has been linked to the presence of AN [8,9] and to the presence of silent myocardial ischemia and silent CAD [10].…”

Section: Introductionmentioning

confidence: 99%

Autonomic neuropathy in asymptomatic subjects with non-insulin-dependent diabetes mellitus and microalbuminuria

Rutter

McComb

Brady

et al. 1998

Clinical Autonomic Research

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Patients with non-insulin-dependent diabetes mellitus (NIDDM) and microalbuminuria (MA) are at increased risk of early death. In NIDDM patients without evidence of heart disease, we examined the links between MA and autonomic neuropathy (AN) and reduced heart rate variability (HRV), both of which have been linked to a poor prognosis. We have studied 43 asymptomatic NIDDM patients with MA and have matched them with 43 normoalbuminuric patients for age, gender, diabetes duration, and smoking status. AN was assessed by heart rate changes to deep breathing, Valsalva, and posture and blood pressure changes to posture and hand grip. Twenty-four hour Holter monitoring was used to evaluate HRV. Patients with MA showed evidence of AN and reduced HRV when compared with normoalbuminuric patients. In multivariate analysis, with measures of AN and HRV as outcome variables, Log albumin excretion rate was a significant independent predictor but stronger predictors were the presence of diabetic retinopathy, age, body mass index, claudication, alcohol consumption, and calcium channel blocker use. The presence of MA is linked to AN and reduced HRV in asymptomatic NIDDM patients. The nature of the relationship is complex, involving multiple relationships with other clinical parameters.

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Section: Introductionmentioning

confidence: 99%

Autonomic neuropathy in asymptomatic subjects with non-insulin-dependent diabetes mellitus and microalbuminuria

Rutter

McComb

Brady

et al. 1998

Clinical Autonomic Research

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“…There are at least three studies which have shown that silent ischaemia is more prevalent in patients with autonomic neuropathy than in those with normal autonomic function [17,59,60] and two of these [59,60] show that the proportion of ischaemic episodes that are silent is higher in patients with autonomic neuropathy. Additional support for an association between autonomic neuropathy and silent myocardial ischaemia is provided by two studies [47,48] that found diabetic patients experienced chest pain later after the onset of ST depression than non-diabetic patients and this delay was related to impairment in the tests of autonomic nervous function.…”

Section: Association Of Diabetic Autonomic Neuropathy With Silent Myomentioning

confidence: 99%

Silent coronary artery disease in diabetes - a feature of autonomic neuropathy or accelerated atherosclerosis?

Airaksinen

2001

Diabetologia

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It is generally accepted that diabetic patients with acute myocardial infarction often present with atypical symptoms and the infarction can be completely painless. Autonomic damage is regarded as the cause for the blunted appreciation of pain during acute coronary events, but both of these contentions are open to discussion. The purpose of this paper is to evaluate critically the information available on these relations. Silent myocardial infarction in patients with diabetesThe concept that silent myocardial infarction is a characteristic of coronary artery disease in the presence of diabetes was originally based on the early report of Bradley and Schonfeld [l]. They found that diabetic patients who were admitted to hospital for myocardial infarction more often had little or no pain during infarction than non-diabetic patients. There is also a necropsy study of 61 patients suggesting that unrecognized myocardial infarction is more common in diabetic subjects [2]. These studies based on hospital and necropsy records cannot definitely prove, however, that painless myocardial infarction is more common in the whole diabetic population because the results could be modified by selection bias. It is reasonable to assume that diabetic patients have a closer medical follow-up and are admitted more readily to hospital for symptoms related to their diabetic status [3], e. g. uncontrolled diabetes, nausea or general weakness. These circumstances could erroneously increase the proportion of painless and atypical infarctions in hospital patients who are diabetic compared with these who are non-diabetic but later reports based on hospital records have failed to show any difference in the frequency of painless acute myocardial infarction between diabetic and non-diabetic patients [3±5].Population-based epidemiological studies are likely to provide more reliable information on the incidence of unrecognized myocardial infarctions in dia- AbstractAsymptomatic coronary artery disease and myocardial infarctions are common in diabetic subjects. The available clinical and epidemiological data suggest that the increased incidence of asymptomatic myocardial infarctions and coronary artery disease in diabetic patients mainly reflects accelerated coronary atherosclerosis and the proportion of silent disease relative to symptomatic disease or episodes is not increased in diabetes. In spite of the theoretical background, there is no convincing clinical or epidemiological evidence that diabetic autonomic neuropathy plays a major part in the lack of ischaemic pain. This is not surprising because the mechanisms of silent myocardial ischaemia are complex and controversial even without diabetes. [Diabetologia (2001) 44: 259± 266]

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“…Briefly, they consisted of measuring RR-interval variations during three tests using a computerized device (QMed, Laurence Harbor, NJ) (13). The Valsalva test, conducted with the patient seated, consisted of forcing exhalation and maintaining a pressure of 40 mmHg for 15 s. The result was expressed as the ratio of RR maximum to RR minimum.…”

Section: Other Cardiovascular Investigationsmentioning

confidence: 99%

Predictive Value of Cardiac Autonomic Neuropathy in Diabetic Patients With or Without Silent Myocardial Ischemia

et al. 2001

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OBJECTIVE -The aim of this study was to determine the predictive value of silent myocardial ischemia (SMI) and cardiac autonomic neuropathy (CAN) in asymptomatic diabetic patients.RESEARCH DESIGN AND METHODS -We recruited 120 diabetic patients with no history of myocardial infarction or angina, a normal 12-lead electrocardiogram (ECG), and two or more additional risk factors. SMI assessment was carried out by means of an ECG stress test, a thallium-201 myocardial scintigraphy with dipyridamole, and 48-h ECG monitoring. CAN was searched for by standardized tests evaluating heart rate variations. Accurate follow-up information for 3-7 years (mean 4.5) was obtained in 107 patients.RESULTS -There was evidence of SMI in 33 patients (30.7%). CAN was detected in 33 of the 75 patients (38.9%) who were tested, and a major cardiac event occurred in 11 of them. Among these 75 patients, the proportion of major cardiac events in the SMI ϩ patients was not significantly higher than that in the SMI Ϫ patients (6 of 25 vs. 5 of 50 patients), whereas it was significantly higher in the CAN ϩ patients than in the CAN Ϫ patients (8 of 33 vs. 3 of 42 patients; P = 0.04), with a relative risk of 4.16 (95% CI 1.01-17.19) and was the highest in the patients with both SMI and CAN (5 of 10 patients). After adjusting for SMI, there was a significant association between CAN and major cardiac events (P = 0.04).CONCLUSIONS -In asymptomatic diabetic patients, CAN appears to be a better predictor of major cardiac events than SMI. The risk linked to CAN appears to be independent of SMI and is the highest when CAN is associated with SMI.

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Silent ischaemia in diabetic men with autonomic neuropathy.

Abstract: Autonomic neuropathy is associated with an increased incidence of silent myocardial infarction and sudden death.

Cited by 52 publications

References 13 publications

Autonomic neuropathy in asymptomatic subjects with non-insulin-dependent diabetes mellitus and microalbuminuria

Autonomic neuropathy in asymptomatic subjects with non-insulin-dependent diabetes mellitus and microalbuminuria

Silent coronary artery disease in diabetes - a feature of autonomic neuropathy or accelerated atherosclerosis?

Predictive Value of Cardiac Autonomic Neuropathy in Diabetic Patients With or Without Silent Myocardial Ischemia

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