Objective:

To determine whether cardiovascular autonomic neuropathy (CAN) and reduced heart rate variability (HRV) predict the development of distal symmetrical polyneuropathy (DSPN) in individuals with diabetes mellitus (DM).

Approach:

• Study Sample: 288 individuals with DM underwent baseline assessment of CAN and HRV indices, followed for 3.0 ± 1.3 years to assess incident DSPN.
• Assessment Methods: DSPN was characterized using clinical criteria, sensory-loss phenotype, and Toronto consensus definition. CAN was assessed using cardiovascular autonomic reflex tests and HRV indices.

Key Findings:

• CAN prevalence was 16.3%, and low HRV indices were present in 18.6–40.2% of participants.
• DSPN prevalence was 27.7%, 17.6%, and 20.8% for the three definitions.
• Baseline CAN independently predicted incident DSPN with adjusted HRs of 6.20, 3.30, and 7.33 across definitions.
• Lower rMSSD, HF power, and LF power predicted incident DSPN according to definitions (i) and (iii), whereas reduced CVRR predicted DSPN defined by criteria (ii).

Interpretation:

Established CAN is a strong predictor of future DSPN.

Limitations:

• The study was limited to a specific cohort and may not generalize to all individuals with diabetes.
• Follow-up duration may not capture all cases of incident DSPN.

Conclusion:

Reduced HRV provides a practical, accessible alternative marker for identifying individuals at elevated neuropathy risk.