Simplified Diagnosis of Cardiovascular Autonomic Neuropathy in Type 2 Diabetes Using Ewing's Battery

Abstract

■ Abstract AIM:To find a potential simplification of the established Ewing's battery for the diagnosis of cardiovascular autonomic neuropathy (CAN) in type 2 diabetes (T2D). METHODS:We included 152 patients (92 men) with mean age 64.51 ± 7.85 years and median diabetes duration of 12 years. Ewing's battery was used as the gold standard for the diagnosis of CAN. Against this, we compared the results from each test and their combinations. RESULTS: The 30:15 ratio exhibited the best diagnostic performance (AUC = 0.817, 95% CI: 0.730-0.903, p < 0.001), with 96% sensitivity, 65% specificity, and 94% negative predictive value (NPV). The corresponding values for the Valsalva ratio (VR) were 62%, 92%, and 85%, respectively. The 30:15 ratio was the strongest independent predictor of neuropathy in multivariate regression analysis; low levels yielded an odds ratio (OR) of 21.14 for CAN. The rise in diastolic blood pressure and the expiration/inspiration/VR ratio (E/I/VR) were also identified as independent predictors of CAN, with 9.45 and 10.79 ORs, respectively. CONCLUSIONS: The 30:15 ratio has the best diagnostic accuracy, primarily in the exclusion of CAN, by virtue of its very high sensitivity and NPV. If this ratio is positive for CAN, the VR, the rise in diastolic blood pressure, and the E/I/VR may be useful to increase diagnostic accuracy. This procedure is a simplified diagnostic approach that merits further evaluation to enable wider screening for CAN.

Diagnosis of cardiovascular autonomic neuropathy in diabetes: as simple as possible, but not simpler? An answer

“…We read the interesting letter of K. Pafili and N. Papanas commenting on our recent paper on autonomic testing [1]. We appreciated that they reached somewhat similar conclusions in a previous work [2]: i.e., the association of HRV on Valsalva manoeuvre (VM) and on lying to standing (LS) is the most reliable tests for autonomic dysfunctions, although we found VM more sensitive than LS, in contrast to what they found.…”

Autonomic Neuropathy—a Prospective Cohort Study of Symptoms and E/I Ratio in Normal Glucose Tolerance, Impaired Glucose Tolerance, and Type 2 Diabetes

“…Since then, several suggestions for simplifying the tests have been published. Some authors advocate the use of the 30:15 ratio as the most simple and accurate test (22) while others promote the deep breathing test (23). The Toronto Expert Group recommends that at least two tests should be used in order to reach a definitive diagnosis of CAN, but argues that the presence of one abnormal test can identify early CAN (15).…”

Cardiac vagal tone, a non‐invasive measure of parasympathetic tone, is a clinically relevant tool in Type 1 diabetes mellitus

“…Thirdly, it does not necessitate labourious data extraction or expertise in its interpretation. In contrast to the challenges in the interpretations of HRV, the single measure given by CVT is conceptually more intuitive, particularly for the non-expert [19]. Fourthly, in healthy participants CVT has been shown to be reproducible after 12 months, suggesting that it is a stable measure [14], and therefore could be potentially used as a longitudinal biomarker for disease/complication progression.…”