title: Why Not to Use the Handgrip Test in the Assessment of Cardiovascular Autonomic Neuropathy Among Patients with Diabetes Mellitus?
abstract: Historically, a set of 5 Cardiovascular Autonomic Reflex Tests (CARTs) were considered to be the gold standard in the assessment of Cardiovascular Autonomic Neuropathy (CAN). However, measuring diastolic Blood Pressure (BP) response to sustained handgrip is omitted in recent guidelines. We aimed to assess the association between the handgrip and the other 4 tests as well as to identify determinants of the handgrip test results in diabetic patients.
  
  
  
  353 patients with diabetes (DM) were recruited (age: 60.2±7.4 years; female: 57.2%; BMI: 29.3±2.1 kg/m2; DM duration: 15.6±9.9 years; HbA1c: 7.8±1.4% (66 mmol/mol); with type 1 DM: 18.1%). CAN was assessed by 5 CARTs: the deep breathing test, Valsalva ratio, 30/15 ratio, handgrip and orthostatic hypotension test.
  
  
  
  Sensitivity and specificity of the handgrip test in the diagnosis of definite CAN were 24.6% (95%CI 17.7-33.1%) and 79.4% (95%CI 73.3-84.4%), respectively. Results of the handgrip test did not show any association with those of the deep-breathing test (y=0.004, p=0.563), 30/15 ratio (y=0.282, p=0.357), Valsalva ratio (y=-0.058, p=0.436) and orthostatic hypotension (y=-0.026, p=0.833). Handgrip test abnormality showed an independent association with higher initial diastolic BP (OR 1.05, p=0.0009) and an independent inverse association with the presence of hypertension (OR=0.42, p=0.006).
  
  
  
  Our data confirm that the handgrip test should no longer be part of the cardiovascular autonomic testing being highly dependent on hypertensive status and baseline diastolic BP. Exaggerated exercise pressor response is proposed as putative mechanism for the inverse association between abnormal results of the handgrip test and hypertension. Adequate CARTs are important to allow their use in clinical trials and for the prevention of DM-associated complications by initiating early treatment.
authors.affiliation: 1st Department of Medicine, Semmelweis University, 1083 Budapest, Korányi S utca 2/A, Hungary. anna.korei@yahoo.com.
authors.forename: Anna E
authors.initials: AE
authors.lastname: Körei
authors.forename: Miklós
authors.initials: M
authors.lastname: Kempler
authors.forename: Ildikó
authors.initials: I
authors.lastname: Istenes
authors.forename: Orsolya E
authors.initials: OE
authors.lastname: Vági
authors.forename: Zsuzsanna
authors.initials: Z
authors.lastname: Putz
authors.forename: Viktor J
authors.initials: VJ
authors.lastname: Horváth
authors.forename: Katalin
authors.initials: K
authors.lastname: Keresztes
authors.forename: Csaba
authors.initials: C
authors.lastname: Lengyel
authors.forename: Ádám Gy
authors.initials: ÁG
authors.lastname: Tabák
authors.forename: Vincenza
authors.initials: V
authors.lastname: Spallone
authors.forename: Péter
authors.initials: P
authors.lastname: Kempler
mesh_terms: D000368:Aged; D001341:Autonomic Nervous System / Q000503:physiopathology*; D015415:Biomarkers / Q000097:blood; D001794:Blood Pressure; D002319:Cardiovascular System / Q000294:innervation*; D003430:Cross-Sectional Studies; D003922:Diabetes Mellitus, Type 1 / Q000097:blood / Q000150:complications* / Q000175:diagnosis; D003924:Diabetes Mellitus, Type 2 / Q000097:blood / Q000150:complications* / Q000175:diagnosis; D003928:Diabetic Nephropathies / Q000097:blood / Q000175:diagnosis* / Q000209:etiology / Q000503:physiopathology; D005260:Female; D006442:Glycated Hemoglobin / Q000378:metabolism; D018737:Hand Strength; D006801:Humans; D006973:Hypertension / Q000175:diagnosis / Q000503:physiopathology*; D007024:Hypotension, Orthostatic / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D009460:Neurologic Examination / Q000379:methods*; D056888:Patient Positioning; D011237:Predictive Value of Tests; D012018:Reflex; D015203:Reproducibility of Results; D015656:Respiratory Mechanics; D014636:Valsalva Maneuver
chemical_list: D015415:Biomarkers; D006442:Glycated Hemoglobin; C517652:hemoglobin A1c protein, human