Central regulation of the heart in type 2 diabetes mellitus

Diabetic heart disease is a leading cause of morbidity and mortality in individuals with type 2 diabetes mellitus (T2DM). A major yet frequently under-recognized component of diabetic heart disease is cardiac autonomic neuropathy (CAN), a condition characterized by dysregulated sympathetic and parasympathetic drive to the heart. Current pharmacological treatments for diabetic CAN are often ineffective, having been extrapolated from other health conditions. These therapies predominantly target the peripheral symptoms of elevated sympathetic activity, whilst largely neglecting its origins in sympathoexcitatory regions of the central autonomic network. Sympathetic control of cardiac function originates from the hypothalamus, medulla oblongata, midbrain, and pons, and is relayed through the intermediolateral cell column of the thoracic spinal cord and the intrinsic cardiac nervous system. Targeting the central autonomic network to modulate cardiac sympathetic drive presents a promising novel therapeutic avenue for the treatment of diabetic CAN. This review briefly summarizes established knowledge regarding the pathophysiology and management of diabetic CAN, and the implications of recent findings of increased neuronal activation in central sympathoregulatory regions early in the development of T2DM. Increased cardiac sympathetic in the intital stages of T2DM might represent a novel therapeutic target to reduce the impact of CAN and thereby improve outcomes in patients with T2DM.