Squatting test: A posture to study and counteract cardiovascular abnormalities associated with autonomic dysfunction.

The squatting test is an active posture manoeuvre that imposes one of the most potent orthostatic stresses. In normal subjects, the changes in blood pressure and heart rate are transient because of appropriate baroreflex homeostasis and do not provoke symptoms. However, in various pathological conditions, both the increase in blood pressure during squatting and the decrease in blood pressure during standing may be more important and sustained, potentially leading to complaints and adverse events. Squatting has been used to evaluate patients with tetralogy of Fallot, heart transplant, dysautonomia, including diabetic cardiovascular autonomic neuropathy, and individuals prone to vasovagal syncope. Careful analysis of changes in blood pressure and heart rate during the transition from standing to squatting and from squatting to standing allows the early detection of altered vagal and/or sympathetic function. Of note squatting position has been proposed as a therapeutic means to counteract the fall in blood pressure in patients suffering from dizziness due to dysautonomia and orthostatic hypotension or presenting pre-syncope symptoms, such as soon after exercise. The aims of the present review are to analyse the haemodynamic pattern during a squatting test in various pathological situations and to describe what may be the negative and positive haemodynamic changes associated with this posture. We were especially interested in using the squatting test for the assessment of cardiovascular autonomic neuropathy associated with diabetes mellitus

Dizziness: hypoglycemia, hypotension or spasmophilia?

peer reviewedThe consultation for dizziness is a common problem in clinical practice. Because of the apparent lack of specificity of the complaints, there is a rather high risk to prescribe a variety of sophisticated exams, which will not be very helpful in absence of a well oriented anamnesis and a pertinent clinical examination. The present paper aims at describing a global medical approach, essentially based upon a detailed anamnesis (semiological, chronological and therapeutical arguments), to which may be added a few simple clinical and technical complementary data. This strategy should allow obtaining quite easily pertinent arguments for a differential diagnosis between reactive hypoglycaemia, (orthostatic) hypotension, and hyperventilation crisis (spasmophilia)

Pulse pressure and cardiovascular autonomic neuropathy according to duration of type 1 diabetes.

peer reviewedBACKGROUND: To evaluate changes in pulse pressure (PP) and markers of cardiovascular autonomic neuropathy (CAN) according to duration of type 1 diabetes mellitus (T1DM). METHODS: This cross-sectional controlled study evaluated 159 diabetic patients during a 3-min posture test (standing-squatting-standing) with continuous measurement of systolic (SBP), diastolic (DBP) and mean (MBP) blood pressure by a Finapres device. Arterial stiffness was indirectly assessed by PP and the slope of PP as a function of MBP calculated during the whole 3-min test. CAN was assessed by the expiration/inspiration pulse interval ratio (E/I R-R ratio) during deep breathing and by three indices measured during the squatting test. Patients were divided into four groups according to diabetes duration ( 30 years from group 1 to group 4, respectively) and compared with age-matched non-diabetic subjects. RESULTS: PP progressively increased (p < 0.0001) and PP/MBP decreased (p < 0.0005) according to T1DM duration, whereas these parameters remained almost unchanged in age-matched control subjects. E/I ratio (p < 0.0001) and baroreflex gain (p < 0.0005) progressively decreased with T1DM duration. The parasympathetic index (squatting test vagal ratio-SqTv) significantly increased (p < 0.0001), whereas the sympathetic index (squatting test sympathetic ratio-SqTs) only tended to decrease (p = 0.12) according to diabetes duration. No such changes in CAN indices were observed in the non-diabetic population. CONCLUSIONS: PP increased according to T1DM duration in an age range where PP remained almost stable in controls, in agreement with accelerated arterial stiffening due to chronic hyperglycaemia. The baroreflex gain decreased and other indices of CAN also deteriorated with diabetes duration, more so indices reflecting parasympathetic rather than sympathetic dysfunction

Effets de la durée du diabète de type 1 sur la pression artérielle pulsée : résultats d’une étude transversale comparative à un groupe contrôle non diabétique.

peer reviewe

Contribution of continuous glucose measurement in the management of gestational diabetes: A pilot study

peer reviewe

Arterial pulse pressure in relation to the duration of type 1 diabetes: a cross-sectional controlled study

Diabetes mellitus and arterial pulse pressure (PP) are two independent cardiovascular risk factors. This cross-sectional study investigated the influence of diabetes duration on PP in type 1 diabetic patients without any cardiovascular disease. PP was measured continuously during 3 minutes (active orthostatic test: 1 min standing--1 min squatting--1 min standing) using a fingertip plethysmograph (Finapres) in 159 type 1 diabetic patients aged 20-60 yrs. They were divided into 4 groups according to diabetes duration: (1) G1 : 30 yrs (n=18). In order to separate the effects of age from the effects of diabetes duration, diabetic patients were compared to age- and sex-matched non diabetic controls. PP (expressed in mmHg; mean +/- SD) was higher in men than in women in both diabetic (58 +/- 15 vs. 50 +/- 14; p = 0.001) and non diabetic subjects (55 +/- 14 vs. 47 +/- 12; p = 0.001). Overall PP was higher in diabetic than in non diabetic individuals (54 +/- 15 vs. 50 +/- 13; p = 0.025). PP progressively increased according to diabetes duration: 47 +/- 16 vs. 51 +/- 13 vs. 59 +/- 14 vs. 62 +/- 12, from G1 to G4 respectively; p or =8% (55 +/- 16), with (57 +/- 17) or without (54 +/- 14) microalbuminuria, treated (56 +/- 14) or not (54 +/- 15) by inhibitors of the renin-angiotensin system. In conclusion, PP progressively increased with the duration of type 1 diabetes, independently of age. Such increase was more marked in squatting than in standing position. The role of such PP rise in the increased cardiovascular risk of patients with type 1 diabetes, although suspected in the recent EURODIAB Prospective Complications Study, deserves further investigation

Les inhibiteurs de SGLT2. L’EXPÉRIENCE BELGE

peer reviewe

Intérêt potentiel des inhibiteurs des SGLT2 dans le traitementdu diabète de type 1

peer reviewe

Potential role of SGLT2 inhibitors in the management of type 1 diabetes

peer reviewedType 1 diabetes (T1D) management is still complex. Some drugs have been proposed as adjunctive treatment to insulin for type 1 diabetes but results are not encouraging. Sodium-glucose cotransporter 2 (SGLT2) inhibitors act independently of insulin and initial proof-of-concept studies related to their use in T1D led to larger phase 3 trials. Several trials have demonstrated some beneficial and consistent effects as HbA1c, body weight and insulin dose reductions, and lesser glycaemic excursions. Nevertheless, adverse events were also reported, especially a higher rate of diabetic ketoacidosis when using gliflozins in T1D. Balance between positive and negative effects must be carefully studied in the near future with data from real-life and large trials dedicated to this potential new help in T1D