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Impaired Autonomic Function Is Associated With Increased Mortality, Especially in Subjects With Diabetes, Hypertension, or a History of Cardiovascular Disease
Open accessAbstract
OBJECTIVE: Measures of baroreflex sensitivity, heart rate variability (HRV), and the classical Ewing test parameters are currently used for the diagnosis of diabetic autonomic neuropathy and for mortality risk stratification after myocardial infarction. However, the strengths of the associations of these measures of autonomic function with risk of mortality have never been compared in one study population. Furthermore, no evidence is available on the possible effect of glucose tolerance on these associations. RESEARCH DESIGN AND METHODS: The study population (n = 605) consisted of a glucose tolerance-stratified sample from a general population (50-75 years of age). Cardiac cycle duration and continuous finger arterial pressure were measured under two conditions: at rest and on metronome breathing. From these readings, seven parameters of autonomic function were assessed (one Ewing, five HRV, and one baroreflex sensitivity). RESULTS: During 9 years of follow-up, 101 individuals died, 43 from cardiovascular causes. Subjects with diabetes and low levels of the autonomic function parameters, indicating impaired autonomic function, had an approximately doubled risk of mortality. This association was consistent, though not statistically significant, for all parameters. The elevated risk was not observed in subjects without diabetes, hypertension, or prevalent cardiovascular disease. CONCLUSIONS: Impaired autonomic function is associated with all-cause and cardiovascular mortality. Moreover, the results of the present study suggest that cardiac autonomic dysfunction in patients already at risk (diabetes, hypertension, or history of cardiovascular disease) may be especially hazardous.
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“Furthermore, despite HRV being linked with the severity of T2DM [23], no studies have comprehensively assessed the role of the most common variables, such as age [24], gender [25], blood glucose control [26], or medications treating for T2DM, on HRV parameters [27,28].”
From Heart rate variability in type 2 diabetes mellitus: A systematic review and meta–analysis (2018) · cites this paper as [23]
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Autonomic Peripheral Neuropathy
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“Coexistence of cardiovascular autonomic neuropathy and LVH, both of which are independent risk factors for major cardiac events such as myocardial infarction or congestive heart failure [1,3–5], is likely to be one of the key factors for poor prognosis in diabetic ESRD Autonomic neuropathy and LVH in diabetic ESRD 2537”
BackgroundScholte, A. J. H. A., Schuijf, J. D., Delgado, V., Kok, J. A., Bus, M. T. J., Maan, A. C., Stokkel, M. P. M., Kharagitsingh, A. V., Dibbets‐Schneider, P., van der Wall, E. E., et al. (2010) · European Journal of Nuclear Medicine and Molecular Imaging · doi:10.1007/s00259-010-1442-0 · Cited by 49
“Furthermore, CAN is one of the most common complications associated with diabetes and has been associated with an increased risk of mortality and major cardiovascular events [4].”
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“Diabetic autonomic neuropathy is related to an increased all-cause mortality risk in diabetic patients (Ewing et al., 1985; Ziegler et al., 1992; Vinik and Erbas, 2001; Gerritsen et al., 2001; Wheeler et al., 2002).”
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Resistant Hypertension: Mechanisms and Treatment
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“A dysfunction of autonomic nervous system has been associated with increased mortality after myocardial infarction (13,14) in patients with diabetes (15,16) and in the general population (17).”
BackgroundCardiovascular autonomic neuropathy: Diagnosis and management
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“In addition, the investigators suggested that cardiovascular autonomic dysfunction in individuals already at high risk (eg, those with diabetes, high blood pressure, or a history of cardiovascular disease) may be particularly hazardous [ 30 ].”
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BackgroundBaroreflex sensitivity and outcomes following coronary surgery
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“cardial ischaemia, ultimately leading to increased arrhythmia susceptibility.(75,76) CAN has been classically demonstrated non-invasively by assessing heart rate variability (HRV) and baroreflex sensitivity.”
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“Impairment of BRS has been shown to be a valuable predictor of future cardiovascular morbidity and mortality in a variety of diseases that are associated with disturbed autonomic function, such as myocardial infarction and diabetes mellitus [8, 9].”
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“Aldosterone is a risk factor for decreased heart rate variability and prolonged QT interval, factors that predict sudden cardiac death [94-96].”
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“Table 3—Association of microalbuminuria or C-AD with cardiovascular and all-cause mortality Model* RR (95% CI)† Cardiovascular mortality All-cause mortality Microalbuminuria 1 3.49 (1.87–6.53) 2.12 (1.36–3.21) 2 2.23 (1.16–4.29) 1.46 (0.92–2.31) 3 2.09 (1.07–4.08) 1.32 (0.83–2.12) 4 2.13 (1.09–4.17) 1.33 (0.83–2.13) C…”
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Cardiac Autonomic Function Correlates with Arterial Stiffness in the Early Stage of Type 1 Diabetes
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“Reduced cardiovascular autonomic function has been associated with increased total mortality and cardiovascular morbidity as well as mortality [17, 18].”
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Autonomic Dysfunction in Diabetes: a Consequence of Cardiovascular Damage
Lefrandt, J. D., Smit, A. J., Zeebregts, C. J., Gans, R. O. B., & Hoogenberg, K. (2010) · Current Diabetes Reviews · doi:10.2174/157339910793499128 · Cited by 38
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“This increased mortality risk appears to be more marked in patients with diabetes, hypertension, or cardiovascular diseases (1).”
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Alternative Quantitative Tools in the Assessment of Diabetic Peripheral and Autonomic Neuropathy
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“Moreover, impaired autonomic function is associated with increased all-cause and cardiovascular mortality so that CAN in patients already at risk (diabetes, hypertension, or history of CVD) may be especially hazardous (Gerritsen et al., 2001).”
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“74 participants were excluded from the study due to CVDs, chronic illness, primary autonomic failure, renal insufficiency or any history of medication intake that can affect CAF and FPG.”
BackgroundInfluentialBaroreceptor sensitivity and diabetes mellitus
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“In the Hoorn study [80] involving hundreds of subjects who had either DM, or hypertension or a history of cardiovascular disease with a 9 year follow-up period, it was shown that the mortality risk from cardiac and other causes was roughly twice greater in those who had DM and concomitant impairment in autonomic funct…”
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“(Grimm et al., 1998) reported lesser baroreflex sensitivity in individuals with low thoracic injuries whereas Houtman et al.”
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Determinants of autonomic dysfunction in idiopathic Parkinson’s disease
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“Arterial hypertension has not been accounted for in previous studies on autonomic dysfunction in IPD, although it has been noted as one of several risk factors for erectile dysfunction [18], impaired heart rate variability [36] or cardiovascular reflexes [13].”
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“Reduced HRV was also demonstrated to predict worse cardiovascular prognosis not only in patients with coronary heart disease [6,7] and heart failure [8,9] but also in diabetic and hypertensive individuals [10,11] and in elderly population [12].”
BackgroundNeurovascular Function and Sudorimetry in Health and Disease
Vinik, A. I., Névoret, M. L., CASELLINI, C. M., & Parson, H. K. (2013) · Current Diabetes Reports · doi:10.1007/s11892-013-0392-x · Cited by 37
“strongest predictor for mortality in diabetes mellitus, independently of baseline CV disease (CVD), diabetes duration , traditional CVD risk factors, and medications [70–72].”
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“Impaired baroreflex sensitivity has been found to be associated with an increased risk of cardiovascular events and mortality in several disorders, such as myocardial infarction (19,27), coronary surgery (28), heart failure (29), diabetes (30), and acute ischemic stroke (7).”
BackgroundRelationship between autonomic neuropathy and hypertension—are we underestimating the problem?
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“Notably, weight loss reverses obesity-related autonomic dysfunction, probably owing to increased cardiac vagal modulation, resulting in increased HRV and a reduction in heart rate (Tsuji et al., 1996; Gerritsen et al., 2001).”
BackgroundThe association between baroreflex sensitivity and blood pressure in children
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“Higher levels of HRV are associated with reduced risk of recurrent events in patients following myocardial infarction and with heart failure (Camm et al., 2004; Gerritsen et al., 2001; Kleiger, Miller, Bigger, & Moss, 1987) and with a lower likelihood of incident heart disease in initially healthy participants in comm…”
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Baroreflex analysis in diabetes mellitus: linear and nonlinear approaches
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“Survival analyses in diabetic subjects showed that impaired autonomic function was consistently associated with an approximately doubled risk of mortality [16].”
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“This association was generally stronger in subjectswith diabetes, hypertension and a history of cardiovascular disease [29].”
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Orthostatic hypertension and major adverse events: a systematic review and meta-analysis
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Validity and Efficacy of the Elite HRV Smartphone Application during Slow-Paced Breathing
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“Loss of HRV was found to be an independent predictor of all-cause and cardiovascular mortality in population-based studies.(8,9) In patients with CAN, vagal impairment can lead to a relative predominance of sympathetic activity in the sympathovagal balance.”
BackgroundInterplay between baroreflex sensitivity, obesity and related cardiometabolic risk factors (Review)
Konstantinidou, S. M., Argyrakopoulou, G., Tentolouris, N., Karalis, V. D., & Kokkinos, A. D. (2021) · Experimental and Therapeutic Medicine · doi:10.3892/etm.2021.10990 · Cited by 31
“In addition, there is evidence that physical activity affects the autonomous nervous system and improves the condition of patients with autonomic disorders (72).”
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Cardiac and pulmonary arterial remodeling after sinoaortic denervation in normotensive rats
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“Changes in baroreflex sensitivity and heart rate variability (HRV), the two main markers of autonomic nervous system activity, have been linked to an increased mortality rate, particularly in hypertensive subjects with a history of cardiovascular disease (La Rovere et al., 1998; Schwartz and La Rovere, 1998; Gerritsen…”
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“[3] J.”
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Imaging of myocardial metabolism
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Vitamin D in the Spectrum of Prediabetes and Cardiovascular Autonomic Dysfunction
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“Diabetes mellitus is frequently associated with cardiovascular autonomic neuropathy (CAN) that represents a serious complication of long-lasting diabetes and contributes significantly to the increased morbidity and mortality of diabetic patients (Ewing et al., 1991; Gerritsen et al., 2001).”
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Cardiovascular Autonomic Neuropathy Is Associated With Macrovascular Risk Factors in Type 2 Diabetes
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“The Hoorn prospective study of glucose tolerance in a general population of Caucasian subjects (50-75 years of age) showed that autonomic dysfunction in patients already at risk (hypertension or history of cardiovascular disease) may be particularly hazardous.(30) From our results, obesity and smoking should also be a…”
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“CAN is strongly associated with cardiovascular morbidity and mortality (1,2).”
BackgroundBaroreflex sensitivity impairment during hypoglycemia: implications for cardiovascular control
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“Baroreflex dysfunction is also associated with an increased risk of cardiac arrhythmias (29) and is a predictor of mortality in the period after a myocardial infarction (15) and in individuals with type 2 diabetes (13).”
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“In consequence baroreflex dysfunction has been associated with a worse outcome in diabetes mellitus [1] and after myocardial infarction [2].”
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“Several prospective studies have outlined the close correlation between increased mortality from cardiovascular causes and AD in diabetics (83).”
BackgroundAssociation between dysfunction of autonomic nervous system activity and mortality in schizophrenia
Hattori, S., Suda, A., Kishida, I., Miyauchi, M., Shiraishi, Y., Fujibayashi, M., Tsujita, N., Ishii, C., Ishii, N., Moritani, T., et al. (2018) · Comprehensive Psychiatry · doi:10.1016/j.comppsych.2018.08.002 · Cited by 23
Delirium in patients with hip fracture is associated with increased heart rate variability
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“sure, while impaired baroreflex sensitivity (BRS) is associated with adverse cardiovascular outcomes [1].”
BackgroundCardiovascular Autonomic Neuropathy
Stevens, M. J. (2008) · Humana Press eBooks · doi:10.1007/978-1-59745-311-0_24 · Cited by 21
Islet Transplantation as a Treatment for Diabetes
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Assessment of autonomic dysfunction in patients with type 2 diabetes using reactive hyperemia
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Metadata
- Authors
- Gerritsen, J., Dekker, J. M., TenVoorde, B. J., Kostense, P. J., Heine, R. J., Bouter, L. M., Heethaar, R. M., & Stehouwer, C. D. A.
- Affiliations
- Vrije Universiteit Amsterdam (NL)
- Department of Epidemiology and Biostatistics, Vrije Universiteit, Amsterdam, the Netherlands
- Venue
- Diabetes Care
- Publisher
- American Diabetes Association
- Published
- 2001-10-01
- Volume
- 24
- Issue
- 10
- Pages
- 1793-1798
- ISSN
- 0149-5992 (ISSN-L)
- 1935-5548
- OpenAlex
- W2141929799
- Cited by
- 456
- References
- 27
- Citations by year
- 2026: 10 · 2025: 8 · 2024: 14 · 2023: 15 · 2022: 14 · 2021: 20 · 2020: 17 · 2019: 17 · 2018: 17 · 2017: 17 · 2016: 22 · 2015: 24 · 2014: 21 · 2013: 32 · 2012: 29
- FWCI
- 10.29
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Diabetes Care (publishedVersion)
- PubMed (publishedVersion)
- VU Research Portal (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Funders
- Diabetes Fonds
- Nederlandse Organisatie voor Wetenschappelijk Onderzoek
- Topics
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Heart Rate Variability and Autonomic Control
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Syncope and Autonomic Disorders
- Health Sciences › Medicine › Cardiology and Cardiovascular Medicine › Cardiovascular Function and Risk Factors
- Keywords
- cardiovascular mortality, all-cause mortality, diabetic autonomic neuropathy, heart rate variability, baroreflex sensitivity, Ewing test, cardiac autonomic dysfunction, diabetes mellitus, hypertension, cardiovascular disease, glucose tolerance, risk stratification
- MeSH terms
- Aged, Autonomic Nervous System Diseases, Cardiovascular Diseases, Female, Heart Rate, Humans, Hypertension, Male, Middle Aged, Respiration, Risk Factors, Supination, Baroreflex, Diabetes Complications
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