Regression and progression of cardiac sympathetic dysinnervation complicating diabetes: An assessment by C-11 hydroxyephedrine and positron emission tomography

Cardiovascular denervation complicating diabetes has been implicated in sudden cardiac death potentially by altering myocardial electrical stability and impairing myocardial blood flow. Scintigraphic evaluation of cardiac sympathetic integrity has frequently demonstrated deficits in distal left ventricular (LV) sympathetic innervation in asymptomatic diabetic subjects without abnormalities on cardiovascular reflex testing. However, the clinical significance and subsequent fate of these small regional defects is unknown. This study reports the results of a prospective observational study in which positron emission tomography (PET) with (-)-[¹¹C]-meta-hydroxyephedrine ([¹¹C]-HED) was used to evaluate the effects of glycemic, control on the progression of small regional LV [¹¹C]-HED retention deficits in 11 insulin-dependent diabetic subjects over a period of 3 years. The subjects were divided into two groups based on attained glycemic control during this period: group A contained six subjects with good glycemic control (individual mean HbA1c < 8%), and group B contained five subjects with poor glycemic control (individual mean HbA1c ≥ 8%). Changes in regional [¹¹C]-HED retention were compared with reference values obtained from 10 healthy aged- matched nondiabetic subjects. At baseline, abnormalities of [¹¹C]-HED retention affected 73% ± 1.4% and 9.9% ± 6.6% of the LV in group A and B subjects, respectively, with g p maximal deficits of LV [¹¹C]-HED retention involving the distal myocardial segments. At the final assessment in group A the extent of the deficits in [¹¹C]-HED retention decreased to involve only 1.7% ± 0.7% of LV (P < .05 v baseline scan), with significant increases in [¹¹C]-HED retention occurring in both the distal and proximal myocardial segments. In contrast, in group B with poor glycemic control the extent of [¹¹C]-HED deficits increased to involve 34% ± 3.5% of the LV (P < .01 v baseline), with retention of [¹¹C]-HED significantly decreasing in the distal segments ([¹¹C]-HED retention index, 0.066 ± 0.003 v 0.057 ± 0.002, P < .05, at baseline and final assessment, respectively). Poor glycemic control was associated with increased heterogeneity of LV [¹¹C]- HED retention, since three of five group B subjects developed abnormally increased [¹¹C]-HED retention in the proximal myocardial segments. In conclusion, defects in LV sympathetic innervation can regress or progress in diabetic subjects achieving good or poor glycemic control, respectively. In diabetic subjects with early cardiovascular denervation, institution of good glycemic control may prevent the development of myocardial sympathetic dysinnervation and enhanced cardiac risk.