Sudden death in type 1 diabetes: The mystery of the ‘dead in bed’ syndrome

doi:10.1016/j.ijcard.2008.06.021

International Journal of Cardiology

Volume 138, Issue 1, 7 January 2010, Pages 91-93

https://doi.org/10.1016/j.ijcard.2008.06.021 Get rights and content

Abstract

Sudden cardiac death is an unpredictable and devastating event, particularly in the young. A significant proportion of sudden deaths in the young are unexplained—no cause is identified either during life or at post-mortem. This is seen in a subgroup of young patients with type 1 diabetes who have dead in bed syndrome, where these victims are in good health, retire to bed, only to be found dead the following morning in a bed which is undisturbed, suggesting no terminal struggle or seizure. The underlying cause of dead in bed syndrome remains unknown, but is likely to be due to a terminal malignant arrhythmia. A plausible hypothesis is that it may be secondary to QT interval prolongation (followed by a degenerate ventricular tachycardia), caused by a number of factors including acute hypoglycaemia, on a background of cardiac autonomic neuropathy, and possible genetic influences. It is envisaged that understanding the causes and triggers of dead in bed syndrome will allow appropriate therapeutic interventions to be initiated in high-risk patients with type 1 diabetes, with the ultimate goal to prevent sudden death.

Section snippets

Sudden cardiac death in the young

Sudden death in the young is a devastating and unpredictable complication of a number of cardiovascular diseases. While underlying coronary artery disease is the major cause of sudden cardiac death in older populations, many other aetiologies contribute to this problem in those aged less than 35 years. In particular sudden cardiac death in the young can be caused by a number of inherited disorders which can affect both the structure of the heart (e.g. hypertrophic cardiomyopathy) or the

Sudden death in type 1 diabetes: the “dead in bed syndrome”

Cardiovascular complications in both type 1 and type 2 diabetes remain a major cause of morbidity and mortality, with both incidence and prevalence continuing to increase world-wide [3]. Mortality in young patients with type 1 diabetes is broadly categorized into two groups; deaths directly related to diabetes, such as acute complications of diabetic ketoacidosis, and deaths not directly related to diabetes, including suicide, and motor vehicle accidents [4], [5]. In some instances, the cause

The mystery of “dead in bed syndrome”: what is the cause?

The underlying cause and mechanisms leading to dead in bed syndrome remains unknown. There is evidence implicating both cardiac autonomic dysfunction and hypoglycaemia as possible predisposing factors. This is because each of these factors may lead to alterations in cardiac repolarisation, and specifically QT interval prolongation, which may ultimately trigger ventricular arrhythmias leading to sudden death (Fig. 1). A prolonged QT interval predicts increased mortality in people with type 1

Acknowledgement

The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [21].

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Cited by (42)

Sudden Cardiac Death in Patients With Type 1 Versus Type 2 Diabetes
2022, Mayo Clinic Proceedings
To investigate the association between type 1 diabetes mellitus (T1D) and type 2 diabetes mellitus (T2D) with risk of sudden cardiac arrest (SCA).
In a prospective community-based study of SCA from February 1, 2002, through November 30, 2019, we ascertained 2771 cases age 18 years of age or older and matched them to 8313 controls based on geography, age, sex, and race/ethnicity. We used logistic regression to evaluate the independent association between diabetes, T1D, T2D, and SCA.
Patients had a mean age of 64.5±15.9 years, were 33.3% female and 23.9% non-White race. Overall, 36.7% (n=1016) of cases and 23.8% (n=1981) of controls had diabetes. Among individuals with diabetes, the proportion of T1D was 6.5% (n=66) among cases and 2.0% among controls (n=40). Diabetes was associated with 1.5-times higher odds of SCA. Compared with those without diabetes, the odds ratio and 95% CI for SCA was 4.36 (95% CI, 2.81 to 6.75; P<.001) in T1D and 1.45 (95% CI, 1.30 to 1.63; P<.001) in T2D after multivariable adjustment. Among those with diabetes, the odds of having SCA were 2.41 times higher in T1D than in T2D (95% CI, 1.53 to 3.80; P<.001). Cases of SCA with T1D were more likely to have an unwitnessed arrest, less likely to receive resuscitation, and less likely to survive compared with those with T2D.
Type 1 diabetes was more strongly associated with SCA compared with T2D and had less favorable outcomes following resuscitation. Diabetes type could influence the approach to risk stratification and prevention of SCA.
When Low Blood Sugars Cause High Anxiety: Fear of Hypoglycemia Among Parents of Youth With Type 1 Diabetes Mellitus
2021, Canadian Journal of Diabetes
Hypoglycemia is the most common acute complication of type 1 diabetes (T1D), and the potential short- and long-term sequelae can cause children and parents to develop significant fear of hypoglycemia (FOH). FOH and associated anxiety can be disruptive to activities of daily living and lead to reduced quality of life. We sought to determine the extent of FOH among parents of children with T1D within our clinic and to identify factors associated with greater FOH.
Two hundred sixty-four parents of youth (2 to 18 years of age; mean ± standard deviation, 12.4±3.5 years) with T1D completed a survey that included demographic and disease-specific questions, the Spielberger State-Trait Anxiety Inventory and the Hypoglycemia Fear Survey---Parent version (HFS-P).
Of the 264 participants, 207 completed the full HFS-P, with a mean score of 67±19 (range, 31 to 119). The most frequent worries related to the child being hypoglycemic while alone or asleep. Higher HFS-P scores were also associated with more frequent and severe hypoglycemic episodes, higher state-trait anxiety scores, use of a continuous glucose monitor and more frequent blood glucose checks. Higher HFS-P scores were also associated with worse parental sleep quality and less parental engagement with treatment plans.
Parents of children with T1D experience FOH, especially during times of high vulnerability. Moreover, FOH could potentially impact clinical care (with parents being reluctant to administer suggested insulin doses) and quality of life (due to parental/child sleep disruption). Further studies are needed to develop and evaluate interventions aimed at reducing FOH in parents of youth with T1D.
L’hypoglycémie est la complication à court terme la plus fréquente du diabète de type 1 (DT1), et les séquelles potentielles à court et à long terme peuvent amener les enfants et les parents à avoir une peur importante de l’hypoglycémie (PH). La PH et l’anxiété associée peuvent perturber les activités de la vie quotidienne et entraîner une diminution de la qualité de vie. Nous avons cherché à déterminer l’importance de la PH parmi les parents des enfants atteints du DT1 de notre clinique et à découvrir les facteurs associés à une plus grande PH.
Deux cent soixante-quatre parents de jeunes (de 2 à 18 ans; moyenne ± écart type, 12,4 ± 3,5 ans) atteints de DT1 ont rempli des enquêtes qui portaient sur des questions démographiques et liées à la maladie, les questionnaires State–Trait Anxiety Inventory (STAI) selon Spielberger et Hypoglycemia Fear Survey – Parent version (HFS-P).
Parmi les 264 participants, 207 ont rempli le questionnaire complet HFS-P auquel ils ont obtenu un score moyen de 67 ± 19 (étendue, 31 à 119). Les inquiétudes les plus fréquentes étaient en lien avec l’enfant qui éprouve des épisodes d’hypoglycémie lorsqu’il est seul ou qu’il dort. Les scores plus élevés au HFS-P ont été associés à des épisodes plus fréquents et plus graves d’hypoglycémie, à des scores plus élevés au STAI, à l’utilisation d’un lecteur de glycémie en continu et à des vérifications plus fréquentes de la glycémie. Les scores plus élevés au HFS-P ont également été associés à une plus mauvaise qualité du sommeil et à une participation parentale moindre aux plans de traitement.
Les parents d’enfants atteints du DT1 éprouvent la PH, particulièrement durant les périodes de grande vulnérabilité. De plus, la PH pourrait potentiellement avoir des répercussions sur les soins cliniques (lorsque les parents sont réticents à administrer les doses d’insuline recommandées) et la qualité de vie (en raison de la perturbation du sommeil des parents et de l’enfant). D’autres études sont nécessaires pour mettre au point et évaluer les interventions qui visent la diminution de la PH des parents de jeunes atteints du DT1.
Cardiovascular disease in type 1 diabetes: A review of epidemiological data and underlying mechanisms
2020, Diabetes and Metabolism
Citation Excerpt :
It is known that hypoglycaemia induces QT lengthening and may therefore be responsible for acute arrhythmias in T1D. Some data suggest that the ‘dead-in-bed’ syndrome might be related to cardiac arrhythmias associated with nocturnal hypoglycaemia [56,57]. It has been found, in non-diabetic subjects, that hypoglycaemia during a hyperinsulinaemic–hypoglycaemic clamp test induced an acquired long QT syndrome that could be prevented by selective β-blockade, indicating that sympathoadrenal stimulation is the main cause of hypoglycaemia-induced QT prolongation [58].
Cardiovascular disease (CVD) is highly prevalent in patients with type 1 diabetes (T1D) and a major cause of mortality. CVD arises earlier in life in T1D patients and is responsible for a significant reduction of at least 11 years’ life expectancy. Also, the incidence of CVD is much more pronounced in patients with T1D onset at an earlier age. However, the factors responsible for increased atherosclerosis and CVD in T1D are not yet totally clarified. In addition to the usual cardiovascular (CV) risk factors, chronic hyperglycaemia plays an important role by promoting oxidative stress, vascular inflammation, monocyte adhesion, arterial wall thickening and endothelial dysfunction. Diabetic nephropathy and cardiac autonomic neuropathy are also associated with increased CVD in T1D. In fact, the CVD risk remains significantly increased even in well-controlled T1D patients who have no additional CV risk factors, indicating that other potential factors are likely to be involved. Hypoglycemia and glucose variability could enhance CV disease by promoting oxidative stress, vascular inflammation and endothelial dysfunction. Furthermore, even well-controlled T1D patients show significant qualitative and functional abnormalities of lipoproteins that are likely to be implicated in the development of atherosclerosis and premature CVD. In addition, recent data suggest that a dysfunctional immune system, which is typical of autoimmune T1D, might also promote CVD possibly through inflammatory pathways. Moreover, overweight and obese T1D patients can manifest additional CV risk through pathophysiological mechanisms resembling those observed in type 2 diabetes (T2D).
Bereavement, Grief and Adult Type 1 Diabetes: Living With Diabetes Today
2020, Canadian Journal of Diabetes
Citation Excerpt :
Cognitive-behavioural therapy (CBT) has been used as an intervention for fear of hypoglycemia to normalize fears and incrementally adjust patient-determined safe blood glucose targets to match medically determined targets (24). It is important to note, however, that, although CBT has been used for fear of hypoglycemia, it has only been shown to improve A1C outcomes in individuals with comorbid MDD expression (24,25). In addition to mental health concerns due to chronic and intense anxiety and fear of hypoglycemia, compensatory responses likely lead to elevated A1C outcomes, which is commonly associated with diabetes distress (1).
Cardiovascular autonomic neuropathy: A silent killer with long reach
2020, Autonomic Neuroscience: Basic and Clinical
Cardiovascular autonomic neuropathy (CAN) is a common and deadly complication of diabetes mellitus, which is frequently overlooked in clinical practice due to its characteristic subtle presentation earlier in disease. Yet, timely detection of CAN may help implementation of tailored interventions to prevent its progression and mitigate the risk of associated complications, including cardiovascular disease (CVD), cardiac arrhythmias, myocardial dysfunction leading to congestive heart failure and all-cause mortality. This review highlights current CAN epidemiology trends, novel mechanisms linking CAN with other diabetes complications and current recommendations for diagnosis and management of the disease in the clinical setting.
Diurnal and twenty-four hour patterning of human diseases: Cardiac, vascular, and respiratory diseases, conditions, and syndromes
2015, Sleep Medicine Reviews
Various medical conditions, disorders, and syndromes exhibit predictable-in-time diurnal and 24 h patterning in the signs, symptoms, and grave nonfatal and fatal events, e.g., respiratory ones of viral and allergic rhinorrhea, reversible (asthma) and non-reversible (bronchitis and emphysema) chronic obstructive pulmonary disease, cystic fibrosis, high altitude pulmonary edema, and decompression sickness; cardiac ones of atrial premature beats and tachycardia, paroxysmal atrial fibrillation, 3rd degree atrial-ventricular block, paroxysmal supraventricular tachycardia, ventricular premature beats, ventricular tachyarrhythmia, symptomatic and non-symptomatic angina pectoris, Prinzmetal vasospastic variant angina, acute (non-fatal and fatal) incidents of myocardial infarction, sudden cardiac arrest, in-bed sudden death syndrome of type-1 diabetes, acute cardiogenic pulmonary edema, and heart failure; vascular and circulatory system ones of hypertension, acute orthostatic postprandial, micturition, and defecation hypotension/syncope, intermittent claudication, venous insufficiency, standing occupation leg edema, arterial and venous branch occlusion of the eye, menopausal hot flash, sickle cell syndrome, abdominal, aortic, and thoracic dissections, pulmonary thromboembolism, and deep venous thrombosis, and cerebrovascular transient ischemic attack and hemorrhagic and ischemic stroke. Knowledge of these temporal patterns not only helps guide patient care but research of their underlying endogenous mechanisms, i.e., circadian and others, and external triggers plus informs the development and application of effective chronopreventive and chronotherapeutic strategies.

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Letter to the EditorSudden death in type 1 diabetes: The mystery of the ‘dead in bed’ syndrome

Abstract

Section snippets

Sudden cardiac death in the young

Sudden death in type 1 diabetes: the “dead in bed syndrome”

The mystery of “dead in bed syndrome”: what is the cause?

Acknowledgement

Am J Cardiol

Int J Cardiol

Sudden cardiac death in the young

Med J Aust

Causes of sudden cardiac death in young Australians

Med J Aust

Global prevalence of diabetes: estimates for the year 2000 and projections for 2030

Diabetes Care

Mortality in childhood-onset type 1 diabetes: a population-based study

Diabetes Care

Long-term mortality in a nationwide cohort of childhood-onset type 1 diabetic patients in Norway

Diabetologia

Sudden death and human insulin: is there a link?

Diabet Med

Short-term mortality in childhood onset insulin-dependent diabetes mellitus: a high frequency of unexpected deaths in bed

Diabet Med

Dead in bed syndrome in young diabetic patients in Norway

Diabet Med

Letter to the Editor
Sudden death in type 1 diabetes: The mystery of the ‘dead in bed’ syndrome