Cardiovascular autonomic neuropathy in patients with type 2 diabetes mellitus. Review

According to the data, obtained in 2024, type 2 diabetes mellitus affects 8% of the global population, totaling 400 million patients worldwide. Cardiovascular autonomic neuropathy is a very common but underestimated complication of type 2 diabetes, occurring in 60% of cases. It causes various cardiovascular diseases, which are the cause of 50­80% of deaths among patients with type 2 diabetes mellitus. The pathogenesis of cardiovascular autonomic neuropathy involves the disruption of insulin’s trophic effects and the toxic effects of hyperglycemia. These disorders cause systemic inflammation and oxidative stress, reduce the synthesis and bioavailability of the vasodilator, anti­­inflammatory, and antiplatelet agent nitric oxide, inhibit the parasympathetic nervous system, and increase the activity of the sympathoadrenal and renin­­angiotensin­­aldosterone systems. Poor glycemic control, insulin resistance, a duration of diabetes of more than 15 years, visceral obesity, smoking, excessive alcohol consumption, arterial hypertension, dyslipidemia, and advanced age are the most significant factors in the development and progression of cardiovascular autonomic neuropathy. Early intensive multifactorial intervention to control all risk factors leads to a more than 50% reduction in the risk of this pathological condition. The main measures for the prevention and treatment of cardiovascular autonomic neuropathy are lifestyle modification and pathogenetic pharmacotherapy, which includes the use of glucagon­­like peptide­­1 receptor agonists, sodium­­dependent glucose cotransporter type 2 inhibitors, metformin, cardioselective β­blockers, blockers of the renin­­angiotensin­­aldosterone system, and combinations of sacubitril and valsartan. The article provides current evidence regarding the epidemiology, pathophysiology, clinical manifestations, diagnosis, complications, and current methods of treatment of cardiovascular autonomic neuropathy.