Kardiovaskuläre Folgen der diabetischen Neuropathie

Die kardiovaskuläre autonome diabetische Neuropathie ist eine häufige Diabeteskomplikation mit schwerwiegenden Folgen: Sie führt zu einer ausgeprägten orthostatischen Hypotonie und erhöht das Mortalitätsrisiko auf etwa das Dreifache. Dennoch bleibt sie vor allem im Frühstadium oft unerkannt oder wird unzureichend abgeklärt. Dieser Beitrag beleuchtet ihre Symptomatik, aktuelle Diagnostik und Therapie mit dem Ziel der Prävention fortgeschrittener Stadien.

Kernaussagen

• Die kardiovaskuläre autonome diabetische Neuropathie (KADN) tritt bei ca. jedem 5. Menschen mit Diabetes auf und geht mit einem etwa 3-fach erhöhten Mortalitätsrisiko einher.

• KADN kann zu einer ausgeprägten orthostatischen Hypotonie, erhöhter intraoperativer kardiovaskulärer Labilität und zu gehäufter Inzidenz von stummen Myokardischämien bzw. -infarkten führen.

• Als frühestes Zeichen einer vagalen KADN gilt die Abnahme der Herzfrequenzvariabilität (HRV), die auf einfache Weise mithilfe autonomer Funktionstests bzw. im Langzeit-EKG nachzuweisen ist.

• Als primäre Ansätze einer Kausaltherapie gelten die möglichst normnahe Diabeteseinstellung, die Lebensstilintervention sowie die konsequente Therapie der Komponenten des metabolischen Syndroms, die als Risikofaktoren angesehen werden.

• Eine ausgeprägte Sinustachykardie kann mit β1-selektiven Betablockern behandelt werden. Bei der orthostatischen Hypotonie werden zunächst die physikalischen Maßnahmen ausgeschöpft.

• Die medikamentöse Behandlung mit Midodrin und/oder Fludrocortison muss sich entlang eines schmalen Pfades orientieren: Ziel sind eine Blutdrucksteigerung im Stehen und gleichzeitige Vermeidung eines deutlichen Blutdruckanstiegs im Liegen.

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