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American Diabetes Association Statement on Cardiac Autonomic Neuropathy

“Given the clinical and economic impact of this complication, testing of diabetic individuals for cardiac autonomic dysfunction should be part of their standard of care” Source: Technical Review, Volume 26, #5, May 2003

Supporting Statements:

  • Page 1553: DAN: “Diabetic autonomic neuropathy (DAN) is a serious and common complication of diabetes…Major clinical manifestations of DAN include resting tachycardia, exercise intolerance, orthostatic hypotension, constipation, gastroparesis, erectile dysfunction, sudomotor dysfunction, impaired neurovascular function, “brittle diabetes,” and hypoglycemic failure.”
  • Page 1556: CAN “Cardiovascular autonomic Neuropathy (CAN) is the most prominent focus because of the life-threatening consequences and the availability of direct tests of cardiovascular autonomic function…CAN results from damage due to the autonomic nerve fibers that innervate the heart and blood vessels and results in abnormalities in heart rate control and vascular dynamics. Reduced heart variation is the earliest indicator of CAN.”
  • Page 1553: “CAN is the most studied and clinically important form of DAN. Meta-analyses of published data demonstrate that reduced cardiovascular autonomic function as measured by heart rate variability (HRV) is strongly associated with an increased risk of silent myocardial ischemia and mortality. The determination of the presence of CAN is usually based on a battery of autonomic function tests…”
  • Page 1570 “The consensus statement sponsored by the ADA and AAN was a synthesis of reviewed research efforts to date in the clinical assessment of neuropathies and offered recommendations for the testing of diabetic neuropathy (including autonomic neuropathy)…Specifically concerning the assessment of CAN, the panel recognized strong evidence for the three tests of heart rate control. The three tests recommended were heart rate response to 1) Deep Breathing, 2) Standing, and 3) The Valsalva Maneuver…These tests were judged suitable for both routine screening and monitoring the progress of autonomic neuropathy”
  • Page 1573: “The economic impact of the recommendation to use autonomic function testing is minimal compared with the economic impact of the catastrophic events related to advanced cardiovascular, cerebrovascular, and renal complications. The relative cost of testing will always be less than the incremental costs of treating either a detected complication or the more catastrophic event that could eventually occur.”

Summary Statement:
Autonomic dysfunction is a prevalent and serious complication for individuals with diabetes. The clinical manifestations of autonomic dysfunction can affect daily activities (e.g. exercise), produce troubling symptoms (e.g., syncope), and cause lethal outcomes. The patient’s history and physical examination are ineffective for early indications of autonomic nerve dysfunction, and thus recommendations for the use of non-invasive tests that have demonstrated efficacy are warranted.

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