title: Effect of autonomic nervous system dysfunction on the circadian pattern of myocardial ischemia in diabetes mellitus.
abstract: OBJECTIVE
  The aim of this study was to determine the prevalence and characteristics of ambulatory myocardial ischemia in patients with diabetes mellitus and to delineate the relation between the presence and severity of autonomic nervous system dysfunction and the incidence and time of onset of myocardial ischemia.
  
  
  BACKGROUND
  Conflicting data exist with regard to the circadian pattern of myocardial infarction and other cardiovascular events, such as ambulatory ischemia, in diabetes.
  
  
  METHODS
  We performed ambulatory electrocardiographic monitoring in 60 patients with diabetes and coronary artery disease. Autonomic nervous system testing was performed in a subgroup of 25 patients with myocardial ischemia after discontinuation of all antianginal medications.
  
  
  RESULTS
  Thirty-eight of 60 patients had evidence of ambulatory ischemia; 91% of all ischemic episodes were asymptomatic. The 25 patients with ambulatory ischemia who underwent autonomic nervous system testing had a peak incidence of ischemia between 6 AM and noon (46 of 133 ischemic episodes, p < 0.007), compared with the other three 6-h periods. Fifteen of the 25 patients had no or mild autonomic nervous system dysfunction and demonstrated a similar peak incidence of ischemia between 6 AM and noon (p = 0.0009). However, the 10 patients with moderate to severe autonomic nervous system dysfunction did not experience a morning peak of ischemia, and the number of ischemic episodes was distributed evenly throughout the day (p = 0.4).
  
  
  CONCLUSIONS
  Silent ischemia is highly prevalent among patients with diabetes and coronary artery disease. Time of onset of ischemia in diabetic patients follows a circadian distribution, with a peak incidence in the morning hours. However, patients with significant autonomic nervous system dysfunction did not demonstrate such a peak, suggesting that alterations in sympathovagal balance may have an effect on the circadian pattern of cardiovascular events.
authors.affiliation: Institute for the Prevention of Cardiovascular Disease, Deaconess Hospital, Harvard Medical School, Boston, Massachusetts 02215.
authors.forename: S
authors.initials: S
authors.lastname: Zarich
authors.forename: S
authors.initials: S
authors.lastname: Waxman
authors.forename: R T
authors.initials: RT
authors.lastname: Freeman
authors.forename: M
authors.initials: M
authors.lastname: Mittleman
authors.forename: P
authors.initials: P
authors.lastname: Hegarty
authors.forename: R W
authors.initials: RW
authors.lastname: Nesto
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001341:Autonomic Nervous System / Q000503:physiopathology*; D002940:Circadian Rhythm; D003327:Coronary Disease / Q000503:physiopathology*; D048909:Diabetes Complications; D015716:Electrocardiography, Ambulatory; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D017202:Myocardial Ischemia / Q000453:epidemiology / Q000209:etiology / Q000503:physiopathology*; D015995:Prevalence