Skip to main content
SpringerLink
Log in

Diabetic retinopathy grade as a predictive marker of severity of cardiovascular disease and mortality: DIVERSE Study Group

  • Original Article
  • Published:
International Journal of Diabetes in Developing Countries Aims and scope Submit manuscript

Abstract

Patients with diabetic retinopathy (DR) are more likely to have subclinical cardiovascular disease. Objective of this study was to assess the prevalence and association of DR grades along with comorbidities in patients with established cardiovascular disease (CVD); association of DR grades beyond ocular morbidity, i.e., long-term outcomes among established CVD; influence of DR grades on prognosis in patients undergoing coronary revascularization. This was a single center, retrospective, data analysis of T2DM patients with established CVD. Goodness of fit was analyzed using Pearson’s chi-square test. DR was observed in 64% (n = 2560) of patients (non-proliferative diabetic retinopathy [NPDR] 37%; proliferative diabetic retinopathy [PDR] 27%). DR and CVD were strongly associated; highest association was observed for congestive heart failure (CHF) (n = 1325), followed by myocardial infarction (MI) (n = 795), unstable angina (UA) (n = 275), and cardiomyopathy (n = 165) (p < 0.00001). Patients with NPDR have greater risk of CHF, MI, UA, and cardiomyopathy vs. PDR [HR 1.32, 1.44, 1.2, and 1.75 respectively]. Five-year all-cause mortality was significantly higher in patients with DR (94.2%; n = 766) vs. that in patients with non-DR (5.78%; n = 47) (p < 0.00001). NPDR patients undergoing CABG (n = 765) had lower 5-year mortality than those underwent PTCA (n = 615) (8.36% vs. 25.85%, p < 0.00001).Three times lower 5-year mortality rate was noted in patients with PDR undergoing CABG vs. that in patients undergoing PTCA (n = 265) (25.3 vs. 72.2%, p < 0.00001). DR was strongly associated with CVD with highest association with CHF, followed by MI, UA, and cardiomyopathy. Cardiovascular events, cerebrovascular events, mortality, and all-cause mortality were higher in patients with DR. Higher risk of mortality was noted in NPDR patients who underwent PTCA than in NPDR patients who underwent CABG.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Camici PG, Crea F. Coronary microvascular dysfunction. N Engl J Med. 2007;356(8):830–40.

    Article  CAS  PubMed  Google Scholar 

  2. Klein R, Klein BE, Moss SE, Cruickshanks KJ. Association of ocular disease and mortality in a diabetic population. Arch Ophthalmol. 1999;117:1487–95.

    Article  CAS  PubMed  Google Scholar 

  3. The BARI Investigators. Seven year outcome in the Bypass Angioplasty Revascularization Investigation (BARI) by treatment and diabetic status. J Am CollCardiol. 2000;35:1122–9.

    Article  Google Scholar 

  4. King SB, Kosinski AS, Guyton RA, Lembo NJ, Weintraub WS, for Emory Angioplasty versus Surgery Trial (EAST) investigators. Eight-year mortality in the Emory Angioplasty Versus Surgery Trial (EAST). J Am CollCardiol. 2000;35:1116–21.

    Article  Google Scholar 

  5. Niles NW, McGrath PD, Malenka D, Quinton H, Wennberg D, Shubrooks SJ, et al. Survival of patients with diabetes and multi-vessel coronary artery disease after surgical or percutaneous coronary revascularization: results of large regional prospective study. J Am CollCardiol. 2001;37:1008–15.

    Article  CAS  Google Scholar 

  6. Bailey CC, Sparrow LM. Co-morbidity in patients with sight-threatening diabetic retinopathy. Eye. 2001;15:719–22.

    Article  CAS  PubMed  Google Scholar 

  7. Sullivan P, Caldwell G, Alexander N, Kohner E. Long-term outcome after photocoagulation for proliferative diabetic retinopathy. Diabet Med. 1990;7:788–94.

    Article  CAS  PubMed  Google Scholar 

  8. Uchio E, Inamura M, Ohno S, Taguchi H, Saeki K. Survival rate after vitreous surgery in patients with diabetic retinopathy. Opthalmologica. 1993;206:83–8.

    Article  CAS  Google Scholar 

  9. Hanis CL, Chu HH, Lawson K, Hewett-Emmett D, Barton SA, Schull WJ, et al. Mortality of Mexican Americans with NIDDM. Diabetes Care. 1993;16:82–9.

    Article  CAS  PubMed  Google Scholar 

  10. Gollamuddi SR, Smidydy WE, Schachat AP, et al. Long-term survival rate after vitreous surgery for complications of diabetic retinopathy. Opthalmology. 1991;98:18–22.

    Article  Google Scholar 

  11. Laakso M. Heart in diabetes: a microvascular disease. Diabetes Care. 2011;34:S145–9.

    Article  PubMed  PubMed Central  Google Scholar 

  12. FilipoCrea C, BaireyMerz N, et al. The parallel tales of microvascular angina and heart failure with preserved ejection fraction: a paradigm shift. Eur Heart J. 2017;38:473–7.

    Google Scholar 

  13. Cheung N, Liew G, Wonga TY. Current approaches to retinopathy as a predictor of cardiovascular risk. Experimental approaches to diabetic retinopathy. Front Diabetes Basel, Karger. 2010;20:203–19.

    Article  CAS  Google Scholar 

  14. Naito R, Miyauchi K. Coronary artery disease and type 2 diabetes mellitus. Int Heart J. 2017;58:475–80.

    Article  CAS  PubMed  Google Scholar 

  15. Wong TY, Mcintosh R. Systemic associations of retinal vascular signs: a review of recent population-based studies. Opthalmic Physiol Opt. 2005;25:195–204.

    Article  Google Scholar 

  16. Wong TY, Mcintosh R. Hypertensive retinopathy signs as risk indicators of cardiovascular morbidity and mortality. Br Med Bull. 2005;73-74:57–70.

    Article  PubMed  Google Scholar 

  17. The BARI Investigators. Comparison of coronary bypass surgery with angioplasty in patients with multi-vessel disease. N Engl J Med. 1996;335:217–25.

    Article  Google Scholar 

  18. The BARI Investigators. The final 10-year follow-up results from the BARI randomization trial. J Am Coll Cardiol. 2007;49:1600–6.

    Article  Google Scholar 

  19. Brownrigg JR, Hughes CO, Burleigh D, Karthikesalingam A, Patterson BO, Holt PJ, et al. Microvascular disease and risk of cardiovascular events among individuals with type 2 diabetes: a population-level cohort study. Lancet Diabetes Endocrinol. 2016;4(7):588–97.

    Article  PubMed  Google Scholar 

  20. Shah K, Gandhi A, Natarajan S. Diabetic retinopathy awareness and associations with multiple comorbidities. Insights from DIAMOND Study. Indian J Endocr Metab. 2018;22:30–5.

    CAS  Google Scholar 

  21. Cheung N, Wang JJ, Klein R, Couper DJ, Sharret AY, Wong TY. Diabetic retinopathy and the risk of coronary heart disease: the Atherosclerosis Risk in Communities Study. Diabetes Care. 2007;30:1742–6.

    Article  PubMed  Google Scholar 

  22. Walraveran I, van den Hurk K, et al. Low grade inflammation and endothelial dysfunction explain the association between retinopathy and left ventricular ejection fraction in men: an 8-year follow-up of the HOORN Study. J Diabetes Complications. 2014;28:819–23.

    Article  Google Scholar 

  23. Bonapace S, Rossi A, Lipari P, Bertolini L, Zenari L, Lanzoni L, et al. Relationship between increased left atrial volume and microvascular complications in patients with type 2 diabetes. J Diabetes Complicat. 2015;29(6):822–8.

    Article  Google Scholar 

  24. Cheung N, Wang JJ, Rogers SL, Brancati F, Klein R, Sharrett AR, et al. Diabetic retinopathy and risk of heart failure. J Am Coll Cardiol. 2008;51(16):1573–8.

    Article  PubMed  Google Scholar 

  25. Ohno T, Takamoto S, Ando J, Morita T, Fujita H, Hirata Y, et al. Diabetic retinopathy and coronary stent implantation of sirolimus-eluting stents. J IntervenCardiol. 2007;20:122–31.

    Google Scholar 

  26. Park SJ, Kang SJ, Virmani R, Nakano M, Ueda Y. In-stent neoatherosclerosis: a final common pathway of late stent failure. J Am Coll Cardiol. 2012;59(23):2051–7.

    Article  PubMed  Google Scholar 

  27. Ohno T, Takamoto S, Motomura N. Diabetic retinopathy and coronary artery disease from the cardiac surgeon's perspective. Ann Thorac Surg. 2008;85(2):681–9.

    Article  PubMed  Google Scholar 

  28. Ohno T, Ando J, Ono M, et al. The beneficial effect of coronary-artery-bypass surgery on survival in patients with diabetic retinopathy. Eur J Cardio-Thoracic Surg. 2006;30:881–6.

    Article  Google Scholar 

  29. Ohno T, Kobayashi J, Sasako Y, et al. The impact of diabetic retinopathy on long- term outcomes following coronary artery bypass graft surgery. J Am Coll Cardiol. 2002;40:428–36.

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Diabetes & Thyroid Care Center, Borivali (West), Mumbai, 400092, India

    Kiran Shah

  2. Aditya Jyot Eye Hospital Pvt. Ltd., Wadala, Mumbai, India

    Sundaram Natarajan

  3. Pulse Cardiac Center, Dadar (E), Mumbai, India

    Milind Phadke

  4. Pune, India

    Onkar C Swami

Authors
  1. Kiran Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sundaram Natarajan
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Milind Phadke
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Onkar C Swami
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Kiran Shah.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

This study was conducted in accordance with the principles of the Declaration of Helsinki, guidelines for good pharmaco-epidemiology practice and local regulatory guidelines. Medical data of the patients who had given their prior consent was collected and analyzed. Being a retrospective, non-interventional study, ethics committee approval was not needed and therefore not obtained.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shah, K., Natarajan, S., Phadke, M. et al. Diabetic retinopathy grade as a predictive marker of severity of cardiovascular disease and mortality: DIVERSE Study Group. Int J Diabetes Dev Ctries 39, 291–296 (2019). https://doi.org/10.1007/s13410-018-0699-x

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13410-018-0699-x

Keywords

Search

Navigation