无症状低血糖及血糖波动对糖尿病心脏自主神经病变的影响

Effects of asymptomatic hypoglycemia and blood glucose fluctuation on diabetic cardiovascular autonomic neuropathy

目的:探讨无症状低血糖及血糖波动对糖尿病心脏自主神经病变(DCAN)的影响。方法:本研究为回顾性研究。选取2018年9月至2021年7月在安徽医科大学附属合肥医院内分泌科住院的2型糖尿病(T2DM)患者。通过动态血糖监测系统(CGMS)收集患者日内平均血糖波动幅度(MAGE)、24 h平均血糖水平(24hMBG)、葡萄糖在目标范围内(血糖为3.9~10.0 mmol/L)时间(TIR)、葡萄糖低于目标范围(血糖<3.9 mmol/L)时间(TBR)和葡萄糖高于目标范围(血糖>10.0 mmol/L)时间(TAR),计算患者总低血糖(血糖<3.9 mmol/L)比例和无症状低血糖(低血糖发作时不伴心悸、头昏、饥饿、出汗、手抖等交感神经兴奋表现)比例。根据CGMS结果及患者有无低血糖症状,将患者分为无低血糖组、有症状低血糖组和无症状低血糖组;根据Ewing试验结果将患者分为DCAN组和无糖尿病心脏自主神经病变(N-DCAN)组。采用单因素方差分析、Kruskal-Wallis H检验和χ^(2)检验进行组间比较,采用多因素logistic回归分析法评价T2DM患者发生DCAN的危险因素。结果:共纳入342例T2DM患者。其中,无低血糖组为246例,有症状低血糖组为44例,无症状低血糖组为52例;DCAN组为214例,N-DCAN组为128例。DCAN的发病率为62.57%(214/342)。与N-DCAN组相比,DCAN组无症状低血糖比例更高(χ^(2)=10.60,P=0.001);与无低血糖组(χ^(2)=10.716,P=0.001)及有症状低血糖组(χ^(2)=5.490,P=0.019)相比,无症状低血糖组DCAN发病率均更高。与N-DCAN组相比,DCAN组患者MAGE、24hMBG和TAR均更高,TIR更低(均P<0.05)。多因素logistic回归分析显示,无症状低血糖和MAGE为T2DM患者发生DCAN的危险因素,OR值(95%CI)分别为2.324(1.093,4.941)和1.456(1.245,1.723)。结论:无症状低血糖和MAGE是DCAN的危险因素。

Objective To investigate the effects of asymptomatic hypoglycemia and blood glucose fluctuation on diabetic cardiovascular autonomic neuropathy(DCAN).Methods This was a retrospective study.Patients with type 2 diabetes mellitus(T2DM)who were hospitalized in the Department of Endocrinology of Hefei Hospital Affiliated to Anhui Medical University from September 2018 to July 2021 were enrolled in this study.The mean amplitude of glycemic excursions(MAGE),24-hour mean blood glucose level(24hMBG),time in range(blood glucose 3.9-10.0 mmol/L,TIR),time below range(blood glucose<3.9 mmol/L,TBR)and time above range(blood glucose>10.0 mmol/L,TAR)were collected through the continuous glucose monitoring system(CGMS).The ratio of total hypoglycemia(blood glucose<3.9 mmol/L)and asymptomatic hypoglycemia(the onset of hypoglycemia is not accompanied by palpitation,dizziness,hunger,sweating,hand shaking and other sympathetic nerve excitations)were calculated.According to the results of CGMS and whether hypoglycemia symptoms occurred,the patients were divided into non hypoglycemia group,symptomatic hypoglycemia group and asymptomatic hypoglycemia group.Patients were divided into DCAN and no-diabetic cardiac autonomic neuropathy(N-DCAN)groups based on the results of the Ewing trial.The t test,One way analysis of variance(ANOVA),Mann‐Whitney U test,Kruskal-Wallis H test and Chi-square test were used to compare the risk factors of DCAN.Multivariate logistic regression analysis was used to evaluate the risk factors of DCAN in T2DM patients.Results A total of 342 T2DM patients were included.Two hundred and forty-six cases were in the non hypoglycemia group,44 cases in the symptomatic hypoglycemia group and 52 cases in the asymptomatic hypoglycemia group.There were 214 patients in the DCAN group and 128 in the N-DCAN group,and the incidence of DCAN was 62.57%(214/342).Compared with N-DCAN group,the proportion of asymptomatic hypoglycemia in N-DCAN group was higher(χ²=10.60,P=0.001).Compared with non hypoglycemia group(χ²=10.716,P=0.001)and symptomatic hypoglycemia group(χ²=5.490,P=0.019),the incidence of DCAN was higher in asymptomatic hypoglycemia group.Patients in the DCAN group had higher MAGE,24hMBG,TAR and lower TIR when compared to the N-DCAN group(all P<0.05).Logistic regression analysis showed that asymptomatic hypoglycemia and MAGE were the risk factors of DCAN in T2DM patients,the odd values(95%CI)were 2.324(1.093,4.941)and 1.456(1.245,1.723)respectively.Conclusions Asymptomatic hypoglycemia and MAGE were the risk factors for DCAN.