title: Cardiovascular autonomic neuropathy in diabetes: clinical impact, assessment, diagnosis, and management.
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.
authors.affiliation: Department of Internal Medicine, University of Tor Vergata, Rome, Italy. vispa@mclink.it.
authors.forename: Vincenza
authors.initials: V
authors.lastname: Spallone
authors.forename: Dan
authors.initials: D
authors.lastname: Ziegler
authors.forename: Roy
authors.initials: R
authors.lastname: Freeman
authors.forename: Luciano
authors.initials: L
authors.lastname: Bernardi
authors.forename: Simona
authors.initials: S
authors.lastname: Frontoni
authors.forename: Rodica
authors.initials: R
authors.lastname: Pop-Busui
authors.forename: Martin
authors.initials: M
authors.lastname: Stevens
authors.forename: Peter
authors.initials: P
authors.lastname: Kempler
authors.forename: Jannik
authors.initials: J
authors.lastname: Hilsted
authors.forename: Solomon
authors.initials: S
authors.lastname: Tesfaye
authors.forename: Phillip
authors.initials: P
authors.lastname: Low
authors.forename: Paul
authors.initials: P
authors.lastname: Valensi
mesh_terms: D001341:Autonomic Nervous System / Q000503:physiopathology*; D001786:Blood Glucose; D002318:Cardiovascular Diseases / Q000175:diagnosis* / Q000188:drug therapy* / Q000503:physiopathology; D003929:Diabetic Neuropathies / Q000175:diagnosis* / Q000188:drug therapy* / Q000503:physiopathology; D019468:Disease Management; D006801:Humans; D011379:Prognosis
chemical_list: D001786:Blood Glucose