Hospital Clínico Universitario de SantiagoHospital Clínico Universitario de Santiago

Disfunción autonómica cardiovascular, riesgo cardiovascular estimado y variabilidad circadina de la presión arterial

Dr. José Cabezas Cerrato

Departamento de Medicina (USC)

Manifestaciones clínicas atribuidas a la NAC

• Disminución de la arritmia respiratoria.

• Taquicardia en reposo.

• Incompleta recuperación de la frecuencia cardiaca (FC) post-ejercicio.

• Disminución o falta de respuesta de la FC y de la PA durante elejercicio.

• Hipotensión ortostática (frecuentemente con HTA en decúbito).

• Hipotensión ortostática postprandial.

• Pérdida de la variabilidad circadiana de la PA.

• Incremento del RCV.

• Inestabilidad eléctrica miocárdica.

• Se asocia a una mayor mortalidad cardiovascular.

Manifestaciones menos frecuentes de la HO

• Hipoperfusión muscular:

• Dolor suboccipital y en escaleno (distribución “en percha”).

• Dolor lumbosacro y en glúteos.

• Manifestaciones que remedan el “robo de la subclavia”.

• Hipoperfusión renal: Oliguria.

• Hipoperfusión de la médula espinal:

• Claudicación.

• Ataxia.

CAN and silentmyocardial ischemia

Diabetes Care 26:1553-1579, 2003

Technical ReviewDiabetic Autonomic

NeuropathyA. Vinik, R. E. Maser, B.

D. Mitchell, and Roy Freeman.

Diabetes Care 26:1553-1579, 2003

Technical ReviewDiabetic Autonomic

NeuropathyA. Vinik, R. E. Maser, B.

D. Mitchell, and Roy Freeman.

DCAN and Mortality

Manifestaciones clínicas atribuidas a la NAC

• Pérdida de la variabilidad circadiana de la PA.

• Patrón no-dipper y su relación:

• Con la disfunción autonómica.

• Con el riesgo cardiovascular.

CARACTER N: 101 % X ± DE

HMEdadIMCCC, H => 94cm.CC, M => 80cm.CC => 94-80cmSP + OBSP-II + OB

5942

4333767963

5843

73/H79/M75/n7862

47±1228 ± 1.4

DM-1DM-2A1C %Evol años

4259

4258

8 ±1.412±8

Características principales de la muestra estudiada-I

Características principales de la muestra estudiada-II

CARACTER n:101 %

MicroAlbMDRD4V < 60HTA:No-dippersFumadores

1715504617

1715504517

SM (IDF)RCV-CI-UK-Fram, 10aRCV-ACV-UK, 10 añosCI > 10ACV > 4

53100814838

5399804838

TAU => 1TAU => 2

5037

5037

Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.

Mean = 0.23Mean + 2 SD

Mean - 2 SD

-20

-15

-10

-5

0

5

10

15

20

80 100 120 140 160 180 200

Diff

eren

ce(a

llda

ta -

data

sam

pled

ever

yho

ur)

Average systolic blood pressure (mm Hg)

PAS - Media de 24 horas

Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.

Mean = -0.28

Mean + 2 SD

Mean - 2 SD

-20

-15

-10

-5

0

5

10

15

20

80 100 120 140 160 180 200

Diff

eren

ce(a

llda

ta -

data

sam

pled

ever

y2

hour

s)

Average systolic blood pressure (mm Hg)

PAS - Media de 24 horas

Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.

Mean = -0.79

Mean + 2 SD

Mean - 2 SD

-20

-15

-10

-5

0

5

10

15

20

80 100 120 140 160 180 200

Diff

eren

ce(a

llda

ta -

data

sam

pled

ever

y3

hour

s)

Average systolic blood pressure (mm Hg)

PAS - Media de 24 horas

Hermida et al. Hermida et al. RevRev EspEsp CardiolCardiol. 2007;60:131. 2007;60:131--138.138.

Mean = -0.85

Mean + 2 SD

Mean - 2 SD

-20

-15

-10

-5

0

5

10

15

20

80 100 120 140 160 180 200

Diff

eren

ce(a

llda

ta -

data

sam

pled

the

first

24 h

ours

)

Average systolic blood pressure (mm Hg)

PAS - Media de 24 horas

.

100

105

110

115

120

125

130

Diurnal mean Nocturnal mean 24-hour mean

G, 0G, 1

SBP

(mm

Hg)

SBP in diabetic patients without (G, 0) or with at least one positive testof autonomic dysfunction (G, 1)

p=0.140p=0.031p=0.253

0.00 4.00 8.00 12.00 16.00 20.00 24.00

TIME (HOURS AFTER AWAKENING)

102

107

112

117

122

127

0

-0° -60° -120° -180° -240° -300° -0°

PHASE (360° = 24 HOURS)

MESOR=116.04

0

00 0

0 0 0

0

0

00

0

MESOR=119.25

1

1

11 1

1 1

1

1

11

1

* *

Circadian pattern of systolic blood pressure in diabetic patientswithout (G, 0) or at least one positive test of autonomic dysfunction (G, 1)

SYST

OL

IC B

LO

OD

PR

ESS

UR

E (m

mH

g)

Comparison p-value for of:

MESOR 0.124Amplitude 0.348

Orthophase 0.342

.

50

55

60

65

70

75

80

Diurnal mean Nocturnal mean 24-hour mean

G, 0G, 1

DB

P(m

mH

g)DBP in diabetic patients without (G, 0) or with at leastone positive test (G, 1) of autonomic dysfunction

p=0.013p=0.334p=0.009

0.00 4.00 8.00 12.00 16.00 20.00 24.00

TIME (HOURS AFTER AWAKENING)

59

63

67

71

75

79

0

-0° -60° -120° -180° -240° -300° -0°

PHASE (360° = 24 HOURS)

MESOR=70.79

0

0 00 0 0

0

0

0

00

0

MESOR=67.44

1

1

1

1 11 1

1

1

11

1

* * * * * * *

Circadian pattern of diastolic blood pressure in diabetic patientswithout (G, 0) or with at least one positive test of autonomic dysfunction (G, 1)

DIA

STO

LIC

BLO

OD

PRES

SUR

E (m

mH

g)

p-value for comparison of:

MESOR 0.024

Amplitude 0.048

Orthophase 0.108

.

40

43

46

49

52

55

Diurnal mean Nocturnal mean 24-hour mean

G 0G, 1

PP(m

mH

g)

PP in diabetic patients without (G, 0) or with at least one positive testof autonomic dysfunction (G, 1)

p<0.001p<0.001p<0.001

0.00 4.00 8.00 12.00 16.00 20.00 24.00

Time (hours after awakening)

42.5

45.0

47.5

50.0

52.5

55.0

0.0

-0° -60° -120° -180° -240° -300° -0°

PHASE (360° = 24 HORAS)

MESOR=45.32

00

00

00

0

00

0

00

1

1

1

1 1

1 1 1

1

11

1

* * * * * * * * * * * *

Circadian pattern of pulse pressure in diabetic patients without (G, 0)or with at least one positive test of autonomic dysfunction (G,1)

PULS

E PR

ESSU

RE

(mm

Hg)

p- value for comparison of:MESOR <0.001Amplitude 0.852Orthophase 0.200

100

105

110

115

120

125

130

Diurnal mean Nocturnal mean 24-hour mean

CHD < 10CHD > 10

SBP

(mm

Hg)

SBP in diabetic patients divided according to risk of coronary heart.

disease (CHD)

p<0.001p=0.002p=0.002

.

50

55

60

65

70

75

80

Diurnal mean Nocturnal mean 24-hour mean

CHD <10CHD > 10

DB

P(m

mH

g)DBP in diabetic patients divided according to risk of coronary heart

disease (CHD)

P=0.747P=0.411P=0.943

.

40

43

46

49

52

55

Diurnal mean Nocturnal mean 24-hour mean

CHD < 10

CHD > 10

PP(m

mH

g)PP in diabetic patients divided according to risk of coronary heart

disease (CHD)

p<0.001p<0.001p<0.001

.

100

105

110

115

120

125

130

Diurnal mean Nocturnal mean 24-hour mean

Risk < 4Risk > 4

SBP

(mm

Hg)

SBP in diabetic patients divided according to risk of stroke

p=0.036p=0.011p=0.083

50

55

60

65

70

75

80

Diurnal mean Nocturnal mean 24-hour mean

Risk < 4Risk > 4

DB

P(m

mH

g)DBP in diabetic patients divided according to risk of stroke

p=0.006p=0.092p=0.007

.

40

44

48

52

56

Diurnal mean Nocturnal mean 24-hour mean

Risk < 4Risk > 4

PP

(mm

Hg)

PP in diabetic patients divided according to risk of stroke

p<0.001p<0.001p<0.001

Dos conclusiones mayores se derivan de esta investigación

• La disfunción autonómica no es la causa, ni tampoco parece ser un factor mayor implicado en la génesis del patrón No-Dipper de la PA en la DM.

• La disfunción autonómica en la DM se relaciona con una PP significativamente elevada, y ésta a su vez, con un elevado riesgo de CI y de ACV.