Objective: Historically, a set of 5 Cardiovascular Autonomic Reflex Tests (CARTs) were considered
to be the gold standard in the assessment of Cardiovascular Autonomic Neuropathy (CAN). However,
measuring diastolic Blood Pressure (BP) response to sustained handgrip is omitted in recent guidelines.
We aimed to assess the association between the handgrip and the other 4 tests as well as to identify
determinants of the handgrip test results in diabetic patients.
Patients and Methods: 353 patients with diabetes (DM) were recruited (age: 60.2±7.4 years; female:
57.2%; BMI: 29.3±2.1 kg/m2; DM duration: 15.6±9.9 years; HbA1c: 7.8±1.4% (66 mmol/mol); with type
1 DM: 18.1%). CAN was assessed by 5 CARTs: the deep breathing test, Valsalva ratio, 30/15 ratio,
handgrip and orthostatic hypotension test.
Results: Sensitivity and specificity of the handgrip test in the diagnosis of definite CAN were 24.6%
(95%CI 17.7-33.1%) and 79.4% (95%CI 73.3-84.4%), respectively. Results of the handgrip test did not
show any association with those of the deep-breathing test (γ=0.004, p=0.563), 30/15 ratio (γ=0.282,
p=0.357), Valsalva ratio (γ=-0.058, p=0.436) and orthostatic hypotension (γ=-0.026, p=0.833). Handgrip
test abnormality showed an independent association with higher initial diastolic BP (OR 1.05, p=0.0009)
and an independent inverse association with the presence of hypertension (OR=0.42, p=0.006).
Conclusion: Our data confirm that the handgrip test should no longer be part of the cardiovascular autonomic
testing being highly dependent on hypertensive status and baseline diastolic BP. Exaggerated exercise
pressor response is proposed as putative mechanism for the inverse association between abnormal
results of the handgrip test and hypertension. Adequate CARTs are important to allow their use in clinical
trials and for the prevention of DM-associated complications by initiating early treatment.