title: Predictive value of cardiac autonomic neuropathy in diabetic patients with or without silent myocardial ischemia.
abstract: 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.
  
  
  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+ patients was not significantly higher than that in the SMI- patients (6 of 25 vs. 5 of 50 patients), whereas it was significantly higher in the CAN+ patients than in the CAN- 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.
authors.affiliation: Department of Endocrinology, Diabetology, and Nutrition, Jean Verdier Hospital, Bondy, France. paul.valensi@jvr.ap-hop-paris.fr
authors.forename: P
authors.initials: P
authors.lastname: Valensi
authors.forename: R N
authors.initials: RN
authors.lastname: Sachs
authors.forename: B
authors.initials: B
authors.lastname: Harfouche
authors.forename: B
authors.initials: B
authors.lastname: Lormeau
authors.forename: J
authors.initials: J
authors.lastname: Paries
authors.forename: E
authors.initials: E
authors.lastname: Cosson
authors.forename: F
authors.initials: F
authors.lastname: Paycha
authors.forename: M
authors.initials: M
authors.lastname: Leutenegger
authors.forename: J R
authors.initials: JR
authors.lastname: Attali
mesh_terms: D000328:Adult; D000368:Aged; D001167:Arteritis / Q000150:complications / Q000000981:diagnostic imaging; D001342:Autonomic Nervous System Diseases / Q000150:complications / Q000175:diagnosis*; D002318:Cardiovascular Diseases / Q000453:epidemiology / Q000209:etiology; D017023:Coronary Angiography; D048909:Diabetes Complications; D004562:Electrocardiography; D005080:Exercise Test; D005500:Follow-Up Studies; D006321:Heart / Q000294:innervation*; D006801:Humans; D007866:Leg; D008875:Middle Aged; D015999:Multivariate Analysis; D009203:Myocardial Infarction / Q000453:epidemiology / Q000209:etiology; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D011187:Posture; D011877:Radionuclide Imaging; D012119:Respiration; D014463:Ultrasonography; D014636:Valsalva Maneuver