THE 2011 AACE GUIDELINES REVIEW THE INFORMATION FOR THE DIABETIC COMPLICATION OF CARDIOVASCULAR AUTONOMIC NEUROPATHY IN PATIENTS WITH DIABETES. THIS IS A SERIOUS COMPLICATION OF DIABETES SO THE FOLLOWING IS PROVIDED FOR PATIENTS VIEWING AND UNDERSTANDING. Cardiovascular autonomic neuropathy is significantly associated with overall mortality (293 [EL 4; review NE], 294 [EL 2; MNRCT]) and in some studies, but not all, with morbidity, such as silent myocardial ischemia, coronary artery disease, stroke, diabetic nephropathy progression, and perioperative morbidity. Some pathogenetic mechanisms may link cardiovascular autonomic neuropathy to cardiovascular dysfunction and diabetic complications (293 [EL 4; review NE]). Cardiovascular autonomic neuropathy assessment may be used for cardiovascular risk stratification in patients with and without established CVD; as a marker for patients requiring more intensive monitoring during the perioperative period and other physiological stresses; and as an indicator for more intensive pharma-cotherapeutic and lifestyle management of comorbid conditions. More recently, it has been shown that cardiovascular autonomic neuropathy may be useful for prediction of cardiovascular risk, and a combination of cardiovascular autonomic neuropathy (295 [EL 3; SS]) and symptoms of peripheral neuropathy increase the odds ratio to 4.55 for CVD and mortality (296 [EL 4; review NE]). Indeed, this is the strongest predictor of CVD risk, far greater than blood pressure, lipoprotein profile, and even adenosine scans (297 [EL 4; NE]). The reported prevalence of diabetic autonomic neuropathy varies widely (7.7%-90%) depending on the cohort studied and the methods used for the diagnosis (298 [EL 4; review NE], 299 [EL 4; review NE]). The most common clinical features, diagnostic methods, and treatment options are presented in Table 11 (261 [EL 3; CSS]). Cardiovascular reflex tests are the criterion standard in clinical autonomic testing (300 [EL 4; position NE]). The most widely used tests assessing cardiac parasympathetic Function are based on the time-domain heart rate response To deep breathing, a Valsalva maneuver, and postural change. Valsalva maneuver must not be performed in patients with proliferative retinopathy. Cardiovascular sympathetic function is assessed by measuring the blood pressure response to orthostatic change and a Valsalva maneuver. The combination of cardiovascular autonomic tests with sudomotor function tests may allow a more accurate diagnosis of diabetic autonomic neuropathy (301 [EL 4; NE]). Patients with DM and features of cardiac autonomic dysfunction, such as unexplained tachycardia, orthostatic hypotension, and poor exercise tolerance, or with other symptoms of autonomic dysfunction, should be evaluated for the presence of cardiovascular autonomic neuropathy. Fig. 2. Algorithm for treatment of neuropathic pain after exclusion of nondiabetic etiologies and stabilization of glycemic control (296 [EL 4; review NE]). IV Ig, intravenous immunoglobulin; TCA, tricyclic antidepressants; SNRI, serotonin-norepinephrine reuptake inhibitor. Screening for cardiovascular autonomic neuropathy should be performed at diagnosis of T2DM and 5 years after the diagnosis of T1DM. Retrospective and prospective studies have suggested a relationship between hyperglycemia and the development and severity of diabetic neuropathy and significant effects of intensive insulin treatment on prevention of neuropathy (302 [EL 4; review NE]). Treating oxidative stress may improve peripheral and autonomic neuropathy in adults with T2DM (303 [EL 1; RCT], 304 [EL 1; RCT], 305 [EL 1; RCT], 306 [EL 1; RCT]). TZDs, which reduce hyperglycemia through reductions in insulin resistance, may also reduce chronic inflammation and potentially affect pathways leading to peripheral neuropathy (307 [EL 4; review NE], 308 [EL 1; RCT], 309 [EL 3; SS]). Fibrates and statins protect against peripheral nerve function decline in adults with T2DM (310 [EL 2; PCS], 311 [EL 2; PCS]). Older adults taking statins show a greater benefit than younger adults because of their higher attributable risk of CVD (312 [EL 4; review NE]). Small studies in patients with DM found that aerobic exercise improved quantitative test results for peripheral nerve function and cardiac autonomic neuropathy (313 [EL 2; PCS]). Among participants and/or those with peripheral neuropathy and DM, balance training is effective in improving balance outcomes and probably reduces risk of falls (314 [EL 3; SS], 315 [EL 2; NRCT single-blinded]). AACE 2011 GUIDELINES REQUIRE A SCREENING AND 5 YEAR FOLLOW UP FOR NORMALS AND GOOD MEDICAL PRACTICE WOULD REQUIRE MORE FREQUENT FOLLOW UP FOR ABNORMALS.