Cardio Risk Increases With Diabetic Retinopathy Progression

Laird Harrison

August 03, 2020

The risk for heart attack, stroke, and even death increases as the severity of diabetic retinopathy increases. Severe retinopathy is linked to a doubling of the risk for cerebrovascular accident or myocardial infarction, results from a new study show.

These findings highlight the importance of coordinated care between ophthalmologists and other physicians, said Bobeck Modjtahedi, MD, from Southern California Permanente Medical Group in Pasadena.

It also provides "a good opportunity for ophthalmologists to use what they find as an educational and motivational tool," he told Medscape Medical News. Modjtahedi presented the results at the virtual American Society of Retina Specialists 2020 Annual Meeting.

Researchers have long known that cardiovascular changes are reflected in the retina. And previous studies have shown a correlation between diabetic retinopathy and the risk for cardiovascular events, independent of other known risk factors.

But those studies were not large enough to establish whether the progression of diabetic retinopathy correlates with increased cardiovascular risk, he explained.

For their retrospective analysis, Modjtahedi and his colleagues analyzed data from patients with type 2 diabetes enrolled in Kaiser Permanente health plans and identified cerebral vascular accidents, myocardial infarctions, and all-cause mortality that occurred in the 5 years after those patients underwent evaluation for retinopathy.

Patients with a history of congestive heart failure, cerebrovascular incidents, or myocardial infarctions were excluded from the analysis.

In the study cohort of 68,206 patients who underwent retinal evaluation, 1680 (2.5%) myocardial infarctions, 2269 (3.3%) cerebrovascular accidents, and 3756 (5.5%) deaths occurred in the subsequent 5 years.

The correlation between the severity of retinopathy, determined with fundus photography, and cardiovascular risk and death was strong, even after adjustment for age, sex, race, smoking status, hypertension history, lipid profile, estimated glomerular filtration rate, insulin use, glitazone use, body mass index, and A1c level.

"The patients with worse retinopathy had worse outcomes," said Modjtahedi.

Table. Adjusted Hazard Ratios for Adverse Events: Patients With vs Without Diabetic Retinopathy

Degree of Diabetic Retinopathy

Cerebrovascular Accident

Myocardial Infarction














These correlations can help ophthalmologists persuade their patients to check in with their primary care physicians, said Modjtahedi.

In fact, he said he tells his own patients that "what I see inside your eye is a reflection of other damage that's probably building in your kidney and your heart."

In some cases, some patients see ophthalmologists more regularly than they see other healthcare providers. "Sometimes they fall through the cracks and might be missing statins or not controlling blood pressure," he noted.

"Really Important Numbers"

"I think the study gave us really important numbers," said Gaurav Shah, MD, from The Retina Institute of St. Louis in Missouri. "It actually gave us odds ratios that you could predict with a good amount of certainty that these patients who have these changes are at a higher likelihood of having this problem."

And being able to tell patients that their risk for death may be almost doubled could be a powerful way to catch their attention, he told Medscape Medical News.

Retinopathy can give physicians a "more personalized view" of the diabetes and cardiovascular disease than other biomarkers, said Modjtahedi. "We're getting a snapshot of the damage inside their blood vessels. It gives us a view longitudinally."

The retina also provides a rare view into changes in the vasculature that can help researchers understand diabetes and cardiovascular disease, he added. In the future, we hope to "fold in these retinopathy findings to try to predict long-term risk and potentially guide treatment."

Shah said he would like to see other studies that confirm these findings and that examine whether similar correlations apply to patients with type 1 diabetes.

But such research is difficult to do outside of a "closed system," such as Kaiser Permanente, where patients' medical records are kept in a central database, he acknowledged.

Modjtahedi receives grant support from Genentech. Shah reports relationships with Allergan, Bausch + Lomb, DORC, Regeneron, Zeiss, Covalent, and Vortex Surgery.

American Society of Retina Specialists (ASRS) 2020 Annual Meeting. Presented July 25, 2020.

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