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International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6
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438

A Comparative Study of Autonomic Function
Sensitivity Testing in Type 2 Diabetes
Chiranjeevi Kumar Endukuru 1, N
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Various studies showed that cardiac autonomic
neuropathy (CAN) in diabetes is strongly associated with microvascular complications
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The scope of the present study is to compare the sensitivity of sympathetic and
parasympathetic function tests in the early detection of autonomic dysfunction in Type 2 diabetics
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e
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The
Sympathetic activity can be tested by using simple tests like blood pressure responses to standing, isometric handgrip test and cold
pressure test
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Results in our study showed that
both Parasympathetic and sympathetic neuropathy was found in diabetics but parasympathetic cardiac autonomic function tests are
more sensitive for the detection of cardiac autonomic neuropathy in type 2 diabetics than sympathetic cardiac autonomic function tests
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Keywords: Type II diabetes mellitus, Sympathetic & Parasympathetic Nervous System, Autonomic neuropathy
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Introduction
Type 2 Diabetes mellitus (formerly noninsulin-dependent
diabetes mellitus (NIDDM) or adult-onset diabetes) is the
most common metabolic and endocrine disorder that is
characterized by hyperglycemia (high blood sugar) in the
context of insulin resistance and shortage of insulin
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Type 2 diabetes makes up about 90% of
cases of diabetes, with the other 10% due primarily to
diabetes mellitus type 1 and gestational diabetes
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Prevalence of type 2 diabetes have increased markedly since
1960 in parallel with obesity
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Type 2 diabetes is typically a chronic disease associated with
a ten-year-shorter life expectancy
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When autonomic nervous system
is affected, it can lead to tachycardia, orthostatic
hypotension, partial paralysis of GIT, Involuntary urination
or defecation, bladder abnormalities and affects the quality of
life of a diabetic patient
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The present study aims that the determination of presence of
cardiovascular autonomic neuropathy is usually based on a
variety of autonomic function tests
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2
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The study also got the
approval from ethical committee
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The individuals of type II diabetes mellitus attending
Endocrinology O
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D
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e
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3) No previous history of any other disease or complications
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Cardiovascular Autonomic function tests were carried out in
the morning, after intimate testing procedures with the
subjects
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Cold Pressor test (cold pressure test): Subject was
instructed regarding the test
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Cold water was taken in a container
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Blood pressure was recorded at the end

Volume 4 Issue 4, April 2015
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1796

International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6
...
438
of 60 seconds of submersion of the limb
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II
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The blood pressure rise is due
to increased sympathetic activity and heart rate rise is due to
decreased parasympathetic activity
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ECG electrodes were connected for lead II recording of ECG
and sphygmomanometer for blood pressure measurement
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Subject
was asked to maintain a pressure of 30% of the maximum
activity in the hand grip dynamometer for about 5 minutes
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III
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Patient is then
asked to stand up and blood pressure is recorded at 0 and 1
minute intervals
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Deep breathing test - This test is used to assess the
parasympathetic activity
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ECG electrodes were connected for
recording Lead II ECG
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Expiration to
inspiration ratio was determined by using the formula
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Valsalva Manoeuver - The valsalva ratio is a measure of
parasympathetic and sympathetic functions
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Nostrils were closed manually
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ECG machine was switched on
for continuous recording
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ECG changes were recorded throughout the procedure, 30
seconds before and after the procedure
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III
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This response is
detected by recording ECG in supine and standing postures
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ECG
electrodes were connected from the subject to the cardiowin
system
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Basal heart rate was recorded by using
cardiowin system
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Heart rate response to standing was determined
by using the formula heart rate in standing position – heart
rate in supine position
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Results
Results were analyzed by ANOVA with SPSS version 17
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The results of the above tests were
compared between the test group (type II diabetes mellitus)
and healthy age matched controls
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36 ± 0
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62 ± 0
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8 ± 7
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17 ± 0
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01**
1
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22 <0
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2 ± 4
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05*

In our study 50 subjects of type 2 diabetes patients who were
selected after using proper exclusion criteria
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e
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All these Parasympathetic
autonomic function tests shows significant P values
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When compared all the autonomic function tests, it was
proved that heart rate response to deep breathing was the
most sensitive test to determine autonomic neuropathy
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This was followed by abnormal heart
rate response to standing (30
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Valsalva ratio was abnormal in 31 patients and normal in 19
cases
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The least sensitive
tests to detect autonomic neuropathy was Blood pressure
response to standing and cold pressor test which were
abnormal in 12 patients and normal in 38 cases
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e
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e
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55 ± 0
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9 ± 0
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2 ± 1
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1 ± 1
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9 ± 0
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20±0
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ijsr
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85 ± 1
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01**
11
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96 <0
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2 ± 1
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05
9
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4
<0
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0 ± 1
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01**
-5
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66 <0
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14 | Impact Factor (2013): 4
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Discussion
Diabetes mellitus is one of the high risk factor for
cardiovascular disease
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DAN is a progressive condition in which
ANS dysfunction is not only more prevalent in diabetics but
also worsens as the disease progresses
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This indicates that cardiac autonomic dysfunction is highly
associated risk factor in DM patients
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This test produces a sensitive,
specific, accurate and reproducible indirect measure of vagal
cardiac function
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Our results in this study was almost matched
with the studies conducted by Fareedabanu AB et al6
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During inspiration the heart rate increases and on
expiration the heart rate decreases
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The neuronal
output from the respiratory center influences the gain of the
afferent and efferent outputs at the nucleus tractus solitarius
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But in diabetics due to the
impairment of parasympathetic system the E: I ratio
decreases
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The
values of Valsalva ratio decreases and percentage of subjects
who get abnormal results (<1
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Ultimately, heart rate response to deep breathing is
decreased only in diabetics due to altered vagal tone as
consequence of CAN and this Valsalva response decreases as
duration of diabetes increases due to progressive nerve
damage
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Rajput et al5
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So in diabetics with autonomic neuropathy there is
abnormal response due to damage to the reflex pathways,
mediating the response
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These values were decreased in diabetic patients as compared
to controls
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Hand grip test values were significantly lower in the diabetic
group compared with the control group in control subjects
during sustained hand grip, there is a sharp rise in blood
pressure of more than 15mmHg
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In controls the heart rate rise due to
decreased parasympathetic activity and contraction of
muscles that activate small fibres in the afferent arm of the
reflex arc, however in diabetic patients the rise is very small
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The cold pressor test (CPT) is a potentially useful indicator
of autonomic neuropathy in diabetes after deep Breathing
test
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This study mainly suggest that attenuated change SBP
in diabetic patients is due to impaired sympathetic response
rather than due to impairment of the afferent limb of the CPT
reflex
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In our study there is a fall in systolic and diastolic blood
pressure responses to standing in diabetics as compared to
the controls
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There is decrease
in cutaneous, splanchnic, total vascular resistance and the
baroreflex compensation is also impaired
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5
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G
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We are also thankful to subjects and all the
technical staff for their contribution in the completion of the
project
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Conclusion
Diabetic Autonomic Neuropathy (DAN) is associated with
cardiovascular risk in people with diabetes mellitus
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Parasympathetic
neuropathy was found in 54% cases, and sympathetic
neuropathy in 22% cases
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Heart rate response to deep
breathing was the most sensitive test to detect CAN followed
by heart rate response to standing and heart rate response to
Valsalva manoeuvre
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Cold pressor test is slightly more sensitive to
detect cardiac sympathetic neuropathy than that of postural
hypotension and Blood pressure to sustained hand grip

Volume 4 Issue 4, April 2015
www
...
net
Licensed Under Creative Commons Attribution CC BY

1798

International Journal of Science and Research (IJSR)
ISSN (Online): 2319-7064
Index Copernicus Value (2013): 6
...
438
The above study revealed that Cardiac autonomic neuropathy
is detected by various cardiac autonomic function tests
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These tests affords a satisfactory method for the quick
detection of CAN
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So this early detection of cardiac
autonomic neuropathy will be of greatly helpful in
recognition of those which are prone to risk of various
cardiovascular complications
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Charts and Graphs

References
[1] Ewing DJ, “The natural history of diabetic autonomic
neuropathy
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[2] Ewing DJ, “Immediate heart rate response to standing:
simple test for autonomic neuropathy in diabetes
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[3] Langer A, Freemann MR,” Detection of silent
myocardial ischemia in diabetes mellitus
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[4] Nazeema
Khatoon,”
Cardiovascular
Autonomic
Neuropathy in Patients with Diabetes Mellitus
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1/Issue-3/Jul-Sep
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Makwana1,” Effect of Duration of Diabetes
patient on Valsalva Ratio
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” Pak J Physiol 2011; 7(1)
[7] Prakash S B,” A cross sectional study for the evaluation
of autonomic nervous system functioning in type 2
diabetes mellitus patients
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2014;
5(1): 3879-3883
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” JIACM 2010; 11(3): 190-4
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[10] G
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Pal, Pravatipal, “Text book of practical
physiology”, 2006
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c “Text book of medical physiology”
11th edition 2006
[13] B
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C
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[14] Michael Swash, “Hutchison‟s clinical methods”,
Twentieth edition, 2000
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Sc
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Sc
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Currently
working
as
a
Tutor/Demonstrator in the Department of physiology, AIIMS
Bhopal
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ijsr

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