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Cardiovascular Autonomic Neuropathy Due to Diabetes Mellitus: Clinical Manifestations, Consequences, and Treatment

Department of Medical Technology (R.E.M.), University of Delaware, Newark, Delaware 19716; Diabetes and Metabolic Research Center (R.E.M., M.J.L.), Research Institute, Christiana Care Health Services, Newark, Delaware 19713; and Diabetes and Metabolic Diseases Center (M.J.L.), Christiana Care Health Services, Wilmington, Delaware 19801

Address all correspondence and requests for reprints to: Raelene E. Maser, Ph.D., Department of Medical Technology, 305F Willard Hall Education Building, University of Delaware, Newark, Delaware 19716. E-mail: rmaser{at}UDEL.EDU.

Context: The aim of this article was to review the importance of the clinical identification of persons with cardiovascular autonomic neuropathy (CAN) and discuss potential treatment interventions.

Evidence Acquisition: A MEDLINE search was conducted for articles published during the last 20 yr. In addition, subsequent references of retrieved articles were reviewed. Search strategies included using key terms such as CAN, heart rate variability, orthostatic hypotension, and diabetes mellitus.

Evidence Synthesis: CAN is a common form of diabetic autonomic neuropathy and causes abnormalities in heart rate control as well as central and peripheral vascular dynamics. The clinical manifestations of CAN include exercise intolerance, intraoperative cardiovascular lability, orthostatic hypotension, painless myocardial ischemia, and increased risk of mortality. CAN contributes to morbidity, mortality, and reduced quality of life for persons with diabetes. The American Diabetes Association has recently published a statement that provides guidelines for prevention, detection, and management of neuropathy, including CAN, for healthcare providers who care for patients with diabetes. Algorithms for the evaluation and treatment of the patient with CAN, even if the patient is asymptomatic, are provided in this review.

Conclusions: Once CAN is identified in a patient with diabetes, healthcare providers may consider altering the prescribed exercise regimen, increasing surveillance for cardiac ischemia, carefully reexamining the list of prescribed medications, and aggressively treating cardiovascular risk factors (e.g. hypertension) that may be associated with the development of CAN.

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