Title : Cardiac autonomic neuropathy: Impact on severe hypoglycemic unawareness and orthostatic hypotension in diabetic dysautonomia- A case series study
Abstract:
Introduction: Diabetic autonomic neuropathy (DAN) impacts cardiovascular health with an increasing prevalence over diabetic course, affecting up to 50% of patients after 15 years. Notably, DAN-associated cardiovascular autonomic neuropathy (CAN) have a mortality rate of 16% to 50% over 5 years. This underscores the critical need for early recognition and proactive management to mitigate its potentially fatal complications. This article is to highlight the critical yet frequently overlooked severe manifestations of DAN, specifically hypoglycemic unawareness and orthostatic hypotension.
Methods: We analyzed two distinct cases of DAN diagnosed with comprehensive cardiovascular autonomic reflex tests (CARTs). Case 1 involves a 27-year-old patient with T1DM suffering from recurrent severe hypoglycemic unawareness, while Case 2 describes a 60- year-old patient with T2DM experiencing debilitating orthostatic hypotension.
Results: For Case 1, after implementing automated insulin delivery system, the glucose management improved significantly. Originally presenting with glucose spikes as high as 440 mg/dL and dangerous drops to 24 mg/dL, the intervention stabilized his glucose levels within a safer range of 300 to 420 mg/dL, effectively reducing the incidence of severe hypoglycemic episodes that previously necessitated emergent dextrose administration.
In Case 2, the initiation of Midodrine and Fludrocortisone markedly improved orthostatic intolerance. Prior to treatment, the patient's BP would fall dramatically from 124/74 mmHg when lying to 64/37 mmHg upon standing, causing significant orthostatic symptoms. Post-treatment, it improved to more stable readings (e.g., from 108/75 mmHg sitting to 92/65 mmHg standing), significantly improving symptoms and enhancing capacity of daily activities.
Conclusion: These cases emphasize the importance of early recognition and individualized management of DAN, particularly its cardiac manifestations. Comprehensive autonomic testing, such as CARTs, plays a pivotal role in confirming the diagnosis and guiding therapeutic decisions. Tailored interventions, including advanced technologies like automated insulin delivery systems for T1DM and pharmacotherapy targeting orthostatic hypotension, can 2 significantly improve patient outcomes and quality of life. These findings advocate for integrating advanced diagnostic and therapeutic strategies into clinical guidelines to better manage the cardiovascular complications associated with diabetes.
Keywords: Dysautonomia; Diabetic Mellitus; Hypoglycemia unawareness; Cardiac autonomic neuropathy; Orthostatic hypotension Work model
Audience Take Away:
- Diabetic autonomic neuropathy (DAN) is a debilitating and fatal complication of diabetes. Particularly, DAN-associated cardiovascular autonomic neuropathy (CAN) has a high mortality requiring early diagnosis and proactive management (work model)
- These cases emphasize early recognition and individualized management of DAN, particularly using the CARTs for its cardiac manifestations
- Tailored interventions, including advanced technologies like automated insulin delivery systems for T1DM and pharmacotherapy targeting neurogenic orthostatic hypotension, can significantly improve patient outcomes and quality of life
- These findings advocate for integrating advanced diagnostic and therapeutic strategies into clinical guidelines to better manage the cardiovascular complications associated with diabetes
