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CLINICAL RESEARCH: HEART FAILURE

Diabetic Retinopathy and Risk of Heart Failure

Ning Cheung, MBBS^_*, Jie J. Wang, PhD^_*,, Sophie L. Rogers, Mepi^_*, Frederick Brancati, MD, MPH, Ronald Klein, MD, MPH, A. Richey Sharrett, MD, DrPH, Tien Y. Wong, MD, PhD^_*,||,_* for the ARIC (Atherosclerosis Risk In Communities) Study Investigators

^_* Centre for Eye Research Australia, University of Melbourne, Melbourne, Australia
Centre for Vision Research, University of Sydney, Sydney, Australia
Departments of Medicine and Epidemiology, Johns Hopkins University, Baltimore, Maryland
Department of Ophthalmology and Visual Science, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
^|| Singapore Eye Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Manuscript received October 1, 2007; revised manuscript received November 16, 2007, accepted November 21, 2007.

^_* Reprint requests and correspondence: Dr. Tien Y. Wong, Centre for Eye Research Australia, University of Melbourne, 32 Gisborne Street, Victoria 3002, Australia. (Email: twong{at}unimelb.edu.au).

Objectives: The purpose of this study was to examine the association of diabetic retinopathy with incident heart failure (HF).

Background: Microvascular disease might play a more prominent role in the pathogenesis of diabetic cardiomyopathy, a major cause of HF in diabetes. Whether diabetic retinopathy, a microvascular complication of diabetes, predicts HF is unclear.

Methods: A population-based study included 1,021 middle-aged type 2 diabetic persons with normal renal function and free of clinical coronary heart disease or HF at baseline. Diabetic retinopathy signs were graded from retinal photographs. Incident HF events were prospectively identified from hospital stay and death records.

Results: There were 125 (12.8%) participants with diabetic retinopathy. After 9-year follow-up, 106 (10.1%) participants developed incident HF events. Persons with retinopathy were more likely to develop HF (cumulative incidence of 21.6%) than those without retinopathy (cumulative incidence of 8.5%). After controlling for age, gender, race, smoking, diabetes duration, insulin use, blood pressure, lipid profile, and other risk factors, participants with retinopathy had more than 2.5-fold higher risk of developing HF than those without retinopathy (hazard ratio [HR] 2.71; 95% confidence interval [CI] 1.46 to 5.05). This association remained significant after further adjustments for glycemic control, carotid atherosclerosis, and serum markers of endothelial dysfunction (HR 2.20, 95% CI 1.08 to 4.47).

Conclusions: The presence of diabetic retinopathy signifies an excess risk of HF, independent of known risk factors. This further supports a contribution of microvascular disease to the development of HF in people with diabetes.

Abbreviations and Acronyms   CI = confidence interval   HbA1c = glycosylated hemoglobin   HR = hazard ratio   IMT = intima-media thickness

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