Coronary artery disease
Ability of Retinopathy to Predict Cardiovascular Disease in Patients With Type 2 Diabetes Mellitus

https://doi.org/10.1016/j.amjcard.2009.01.345Get rights and content

It is important identify patients with very high cardiovascular risk to intensify their therapy. Our aim was to assess the association between retinopathy and incident cardiovascular events (cardiovascular disease [CVD]) in patients with type 2 diabetes mellitus (DM). Patients were included if they had type 2 DM and a visible fundus. Baseline clinical and biochemical variables, including urinary albumin excretion rate, were collected. Clinical end points were nonfatal or fatal cardiovascular events (unstable angina including revascularization, nonfatal or fatal myocardial infarction, transient ischemic attack, nonfatal or fatal stroke, lower-leg amputation, terminal chronic heart failure, sudden death). Cox multivariate regression models were used to evaluate the risk associated with each variable and the independent contribution of baseline retinopathy. A total of 458 patients were included, with mean follow-up time of 6.7 ± 2.6 years. Incident CVD rates were 30.7 per 1,000 patient-years in patients with a normal fundus, 56.7 in patients with nonproliferative retinopathy, and 90.7 in patients with proliferative retinopathy (p <0.0001). In multivariate analysis, nonproliferative retinopathy (hazard ratio 1.71, 95% confidence interval 1.1 to 2.66, p = 0.017) and proliferative retinopathy (hazard ratio 2, 95% confidence interval 1.1 to 3.56, p = 0.019) were significantly associated with incident CVD. In conclusion, retinopathy proved to be an independent risk marker for CVD in patients with type 2 DM.

Section snippets

Methods

The study design has been previously reported.9 Briefly, we included patients with type 2 DM who consecutively attended the outpatient endocrinology service of Alcañiz Hospital (Teruel, Spain) from 1994 to 1998 (n = 463) after obtaining an informed consent. Inclusion criteria were the presence of diabetes diagnosed according to World Health Organization criteria prevailing at the time,10 age >35 years at time of diagnosis, and insulin independence for ≥1 year after diagnosis of the disease.

Results

A total of 458 patients (181 men and 277 women) were included in the study. Vital status could be ascertained for 456 patients (99.6%). Baseline characteristics of the cohort are listed in Table 1.

Mean follow-up time was 6.7 ± 2.6 years. There were 131 cardiovascular events, 28 fatal and 103 nonfatal, including 23 unstable anginas, 27 nonfatal myocardial infarctions, 12 fatal myocardial infarctions, 2 deaths due to chronic heart failure, 10 sudden deaths, 17 transient ischemic attacks, 30

Discussion

In our cohort of type 2 diabetic patients, we have shown that baseline retinopathy was associated with incident CVD irrespective of other well-established cardiovascular risk factors. Interestingly, this association was also significant after adjusting for other micro- and macrovascular complications.

In epidemiologic studies adjusted for proteinuria, the independent contribution of retinopathy to incident CVD has not been universally demonstrated. Studies by Targher et al1, 2 showed how the

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