We investigated the characteristics of decreased heart rate variability (HRV) in diabetic patients with ischemic heart disease (IHD). Twenty-one healthy control subjects, 17 diabetic patients without IHD, and 33 diabetic patients with IHD were studied. The diabetic patients with IHD were subdivided into 2 groups according to the severity of their IHD: severe or mild. HRV was evaluated in all subjects using the spectral variables of the all-frequency, low-frequency, high-frequency (AF, LF, HF) components and the LF/HF ratio were determined from Holter recordings. The AF and LF components in patients with diabetes only or diabetes and severe IHD were significantly lower than in control group, but the HF component was significantly lower only in the group of patients with diabetes and severe IHD. The LF/HF ratio did not differ significantly among the 4 groups, but was the lowest in diabetic patients without IHD. Patients with diabetes and mild IHD showed a slight decrease in HRV, but this was not significant. With regard to the circadian rhythm of HRV, the AF and LF components in patients with diabetes-only or diabetes and severe IHD were significantly decreased and showed the same pattern throughout the day. However, the HF component was decreased during more time zones in patients with diabetes and severe IHD, whereas the LF/HF ratio was lower during more time zones in the diabetes-only group. All spectral variables showed a tendency to be inversely related to the duration of diabetes in all diabetic patients. In particular, the LF/HF ratio showed a significant negative correlation. The HRV of diabetic patients was characterized by a decreased LF/HF ratio. It was concluded that, although HRV in diabetic patients with severe IHD was reduced mainly as a result of diabetic neuropathy, this was also partly due to a decline in parasympathetic tone as a result of myocardial injury.