Methodist Journal

FEATURED GUEST EDITOR

ISSUE INTRO

The Scourge of Cardiogenic Shock

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RECOGNITIONS

Arvind Bhimaraj, MD, MPH, Guides Issue on Cardiogenic Shock

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REVIEW ARTICLES See More

Pathophysiology and Advanced Hemodynamic Assessment of Cardiogenic Shock

Cardiogenic Shock in the Setting of Acute Myocardial Infarction

Cardiogenic Shock in Patients with Advanced Chronic Heart Failure

Acute Mechanical Circulatory Support for Cardiogenic Shock

Management of Cardiogenic Shock in a Cardiac Intensive Care Unit

Physiological Concepts of Cardiogenic Shock Using Pressure-Volume Loop Simulations: A Case-Based Review

Systems of Care in Cardiogenic Shock

Cardiogenic Shock in Perioperative and Intraoperative Settings: A Team Approach

CASE REPORTS See More

COVID-19: A Potential Risk Factor for Acute Pulmonary Embolism

Repair of Extent III Thoracoabdominal Aneurysm in the Presence of Aortoiliac Occlusion

Williams-Beuren Syndrome: The Role of Cardiac CT in Diagnosis

A Rare Case of Pancreatitis-Induced Thrombosis of the Aorta and Superior Mesenteric Artery

MUSEUM OF HMH MULTIMODALITY IMAGING CENTER See More

A T2-Weighty Discovery: Aortitis on Cardiac MRI with Histopathologic Correlation

CLINICAL PERSPECTIVES See More

POINTS TO REMEMBER

Acute Kidney Injury in Cardiogenic Shock

EXCERPTA

Cardio-Oncology, Then and Now: An Interview with Barry Trachtenberg

POINTS TO REMEMBER

Onconephrology: An Evolving Field

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Herbal Nephropathy

EDITORIALS

Letter to the Editor in Response to “Cardiac Autonomic Neuropathy in Diabetes Mellitus”

Vol 15, Issue 2 (2019)

Article Full Text

EDITORIALS

Letter to the Editor in Response to “Cardiac Autonomic Neuropathy in Diabetes Mellitus”

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Article Citation:

Chhabra L, Goyal A, Prabahakar Y, Khalid N. Letter to the Editor in Response to “Cardiac Autonomic Neuropathy in Diabetes Mellitus”. Methodist DeBakey Cardiovasc J. 2019;15(2):164.



Keywords
cardiovascular autonomic neuropathy , CAN , diabetes mellitus , Takotsubo cardiomyopathy , stress-induced cardiomyopathy

February 17, 2019

To the Editor:

Agashe et al. presented an excellent review on diabetes mellitus (DM)-induced cardiovascular autonomic neuropathy (CAN) and its associated clinical morbidity and mortality.1 The authors succinctly described multiple clinical manifestations and comorbidities of CAN, such as orthostasis, resting tachycardia, exercise intolerance, increased risk of ischemic heart disease, silent myocardial infarction, and intraoperative cardiovascular morbidity and mortality,1,2 However, DM-induced CAN has recently been recognized as having a protective effect against stress-induced cardiomyopathy.

Takotsubo cardiomyopathy (TC), also known as stress-induced cardiomyopathy, is a syndrome characterized by transient regional systolic dysfunction of the left ventricle that occurs in the absence of angiographic evidence of significant obstructive coronary artery disease.3 An increased catecholamine surge leading to exaggerated cardiac sympathetic stimulation has long been thought to be the most plausible mechanism of TC pathogenesis. Exaggerated sympathetic stimulation from markedly elevated plasma catecholamine levels (both epinephrine and norepinephrine) can lead to catecholamine-mediated myocardial stunning or direct catecholamine myocardial toxicity.3-5 In a recent large meta-analysis of 959 papers comprising a total of 33,894 patients with TC, the prevalence rates of DM were significantly lower in TC than in similar age-matched populations.5 Recent data suggests that DM may be protective against the development of TC due to associated neuropathic changes in splanchnic autonomic sympathetic nerves or in adrenal chromaffin cells that are innervated by these autonomic nerves, thereby resulting in hyposecretion of epinephrine by the adrenals.

One may thus speculate that diabetic patients with more severe disease or prolonged disease duration may be comparatively more immune towards the development of TC.3,4 However, almost certainly, the interplay of factors such as DM, the physical and emotional magnitude of the stressful stimulus, and the presence and severity of associated comorbid conditions would collaboratively play a role in the pathogenesis of TC.

Further prospective studies are needed to strengthen our understanding of the pathophysiological basis of TC and to further explore the relationship between diabetic CAN and TC. Since TC is not a benign illness as was thought previously, the potential role of autonomic denervation as one of the therapeutic measures may be explored in future studies to decrease and/or prevent recurrences of TC in high-risk patients.

Lovely Chhabra, MDa; Amandeep Goyal, MDb; Yogeesh Prabahakar, BSa; Nauman Khalid, MDc
aHeartland Regional Medical Center, Marion, Illinois
bMarietta Memorial Hospital, Marietta, Ohio
cWashington Hospital Center, Washington, DC

 

RESPONSE FROM THE GUEST EDITORS:

We thank Dr. Chhabra and colleagues for their interesting additional information about diabetes mellitus-induced cardiovascular autonomic neuropathy and its potential protective role against Takotsubo cardiomyopathy.

Archana Sadhu, MD; Steven Petak, MD, JD
Houston Methodist Hospital, Houston, Texas

References
  1. Agashe A, Petak S. Cardiac Autonomic neuropathy in Diabetes Mellitus. Methodist Debakey Cardiovasc J. 2018 Oct-Dec;14(4):251-256.
  2. Chhabra L, Liti B, Kuraganti G, Kaul S, Trivedi N. Challenges in the management of type 2 diabetes mellitus and cardiovascular risk factors in obese subjects: what is the evidence and what are the myths? Int J Endocrinol. 2013;2013:856793.
  3. Gowdar S, Syal S, Chhabra L. Probable protective role of diabetes mellitus in takotsubo cardiomyopathy: a review. Vessel Plus. 2017 Sep 26;1:129-36.
  4. Chhabra L. Brain-Heart Disconnection: A Protective Effect of Diabetes Mellitus in Takotsubo Cardiomyopathy. Am J Cardiol. 2016 Jun 1;117(11):1858.
  5. Madias JE. Low prevalence of diabetes mellitus in patients with Takotsubo syndrome: a plausible ‘protective’ effect with pathophysiologic connotations. Eur Heart J Acute Cardiovasc Care. 2016 Apr;5(2):164-70.

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