Diabetes and cardiac autonomic neuropathy: Clinical manifestations, cardiovascular consequences, diagnosis and treatment

Table 1 Cardiovascular autonomic reflex tests[1]

Test	Technique	Normal response and values
Beat-to-beat HRV	With the patient at rest and supine, heart rate is monitored by ECG while the patient breathes in and out at 6 breaths per minute, paced by a metronome or similar device	A difference in heart rate of > 15 beats per minute is normal and < 10 beats per minute is abnormal. The lowest normal value for the expiration-to inspiration ratio of the R-R interval decreases with age: age 20-24 yr, 1.17; 25-29, 1.15; 30-34, 1.13; 35-39, 1.12; 40-44, 1.10; 45-49, 1.08; 50-54, 1.07; 55-59, 1.06; 60-64, 1.04; 65-69, 1.03; and 70-75, 1.02
Heart rate response to standing	During continuous ECG monitoring, the R-R interval is measured at beats 15 and 30 after standing	Normally, a tachycardia is followed by reflex bradycardia. The 30:15 ratio should be > 1.03
Heart rate response to the Valsalva maneuver	The subject forcibly exhales into the mouthpiece of a manometer to 40 mmHg for 15 s during ECG monitoring	Healthy subjects develop tachycardia and peripheral vasoconstriction during strain and an overshoot bradycardia and rise in blood pressure with release. The normal ratio of longest R-R to shortest R-R is > 1.2
Systolic blood pressure response to standing	Systolic blood pressure is measured in the supine subject. The patient stands and the systolic blood pressure is measured after 2 min	Normal response is a fall of < 10 mmHg, borderline fall is a fall of 10-29 mmHg and abnormal fall is a decrease of > 30 mmHg with symptoms
Diastolic blood pressure response to isometric exercise	The subject squeezes a handgrip dynamometer to establish a maximum. Grip is then squeezed at 30% maximum for 5 min	The normal response for diastolic blood pressure is a rise of > 16 mmHg in the other arm

HRV: Heart rate variability; ECG: Electrocardiogram.