1. Autonomic neuropathy is a common complication of diabetes mellitus and is a major risk factor for sudden death.

2. A group of 30 patients with insulin-dependent diabetes mellitus and 30 age-, sex- and blood pressure-matched control subjects underwent traditional tests of autonomic function. Resting supine R—R interval and systolic blood pressure variability were assessed using spectral analysis methods. In addition, we assessed the baroreceptor—cardiac reflex from the linear relation of the change in R—R interval to the increasing systolic blood pressure measured noninvasively with the Finapres monitor during phase 4 of the Valsalva manoeuvre and from resting heart rate and systolic blood pressure power spectra.

3. Whereas standard tests of autonomic function revealed no differences between patients with insulin-dependent diabetes mellitus and control subjects, there was a significant reduction in power spectral density of heart rate variability around the high-frequency region (125.2 ± 112.9 versus 459.3 ± 189.8 ms2, mean ± SD). Furthermore, reductions in baroreflex sensitivity calculated from the Valsalva manoeuvre were detected in diabetics compared with controls (3.3 ± 1.6 versus 9.5 ± 2.5 ms/mmHg, mean ± SD, P > 0.00001). There were significant relations between impairment of the baroreflex and duration of diabetes (P > 0.001) and poor diabetic control (P > 0.05).

4. In summary, autonomic dysfunction occurs much more frequently in diabetic patients than conventional tests would suggest. Abnormal baroreceptor—cardiac reflex sensitivity in patients with insulin-dependent diabetes mellitus may in part be explained by abnormal parasympathetic function. This unrecognized abnormality may have a role in the increased incidence of sudden death seen in young diabetic subjects.

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