Key result
Incremental adrenaline infusion in type 1 diabetes patients with established cardiac autonomic neuropathy caused abnormal cardiac repolarisation, with a significantly lower AUC for T wave area symmetry ratio compared to patients with normal autonomic function (1.19 vs 1.36, p=0.04).
Why the study?
The authors sought to examine the effect of a standardized sympathetic stimulus, incremental adrenaline infusion, on cardiac repolarisation in type 1 diabetes across differing stages of autonomic neuropathy.
Does incremental adrenaline infusion alter cardiac repolarisation differently in type 1 diabetes patients with cardiac autonomic neuropathy compared to those with normal autonomic function?
Observational (n=22)
No
Does incremental adrenaline infusion alter cardiac repolarisation differently in type 1 diabetes patients with cardiac autonomic neuropathy compared to those with normal autonomic function?
Patients with type 1 diabetes and established cardiac autonomic neuropathy exhibit abnormal cardiac repolarisation at lower adrenaline concentrations, suggesting an increased vulnerability to arrhythmias during sympathoadrenal stress such as hypoglycemia.
May heighten arrhythmia vulnerability during sympathoadrenal stress in type 1 diabetes with CAN; hypothesis-generating and needs prospective confirmation.
Aims/hypothesis We examined the effect of a standardised sympathetic stimulus, incremental adrenaline (epinephrine) infusion on cardiac repolarisation in individuals with type 1 diabetes with normal autonomic function, subclinical autonomic neuropathy and established autonomic neuropathy. Methods Ten individuals with normal autonomic function and baroreceptor sensitivity tests (NAF), seven with subclinical autonomic neuropathy (SAN; normal standard autonomic function tests and abnormal baroreceptor sensitivity tests); and five with established cardiac autonomic neuropathy (CAN; abnormal standard autonomic function and baroreceptor tests) underwent an incremental adrenaline infusion. Saline (0.9% NaCl) was infused for the first hour followed by 0.01 μg kg −1 min −1 and 0.03 μg kg −1 min −1 adrenaline for the second and third hours, respectively, and 0.06 μg kg −1 min −1 for the final 30 min. High resolution ECG monitoring for QT c duration, ventricular repolarisation parameters (T wave amplitude, T wave area symmetry ratio) and blood sampling for potassium and catecholamines was performed every 30 min. Results Baseline heart rate was 68 (95% CI 60, 76) bpm for the NAF group, 73 (59, 87) bpm for the SAN group and 84 (78, 91) bpm for the CAN group. During adrenaline infusion the heart rate increased differently across the groups ( p = 0.01). The maximum increase from baseline (95% CI) in the CAN group was 22 (13, 32) bpm compared with 11 (7, 15) bpm in the NAF and 10 (3, 18) bpm in the SAN groups. Baseline QT c was 382 (95% CI 374, 390) ms in the NAF, 378 (363, 393) ms in the SAN and 392 (367, 417) ms in the CAN groups ( p = 0.31). QT c in all groups lengthened comparably with adrenaline infusion. The longest QT c was 444 (422, 463) ms (NAF), 422 (402, 437) ms (SAN) and 470 (402, 519) ms (CAN) ( p = 0.09). T wave amplitude and T wave symmetry ratio decreased and the maximum decrease occurred earlier, at lower infused adrenaline concentrations in the CAN group compared with NAF and SAN groups. AUC for the symmetry ratio was different across the groups and was lowest in the CAN group ( p = 0.04). Plasma adrenaline rose and potassium fell comparably in all groups. Conclusions/interpretation Participants with CAN showed abnormal repolarisation in some measures at lower adrenaline concentrations. This may be due to denervation adrenergic hypersensitivity. Such individuals may be at greater risk of cardiac arrhythmias in response to physiological sympathoadrenal challenges such as stress or hypoglycaemia.
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Bernjak et al. (2020) conducted an observational in Type 1 diabetes (n=22). Incremental adrenaline infusion vs. Normal autonomic function was evaluated on AUC for T wave area symmetry ratio (p=0.04). Incremental adrenaline infusion in type 1 diabetes patients with established cardiac autonomic neuropathy caused abnormal cardiac repolarisation, with a significantly lower AUC for T wave area symmetry ratio compared to patients with normal autonomic function (1.19 vs 1.36, p=0.04).
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