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Retinopathy Predicts Cardiovascular Mortality in Type 2 Diabetes

Proliferative retinopathy in male and female patients with type 2 diabetes may predict coronary heart disease (CHD), but in women, background retinopathy predicted all-cause, cardiovascular disease, and CHD mortality, according to the results of a study. "Population-based studies have shown that microvascular complications predict cardiovascular disease (CVD) mortality not only in type 1 and type 2 diabetic subjects but even in nondiabetic subjects and in general population samples, controlling for the effect of glucose status," write Auni Juutilainen, MD, of the University of Kuopio in Finland, and colleagues. "These observations suggest similar underlying pathogenic processes in microvascular complications and in atherosclerotic CVD in diabetes. It has been suggested that microvascular processes might be especially important in the development of coronary heart disease (CHD) in women."

To evaluate the predictive value of retinopathy for all-cause, CVD, and CHD mortality by sex, the investigators performed an 18-year follow-up study of 824 Finnish subjects with type 2 diabetes (425 men and 399 women) who were free of CVD at baseline. Based on standardized clinical ophthalmoscopy, findings were classified as "no retinopathy," "background retinopathy," and "proliferative retinopathy." The primary outcomes were all-cause, CVD, and CHD mortality.

In men, adjusted Cox model hazard ratios (HRs) of all-cause, CVD, and CHD mortality were 1.34, 1.30, and 1.18, respectively, for background retinopathy and 3.05, 3.32, and 2.54, respectively, for proliferative retinopathy. In women, the corresponding HRs were 1.61, 1.71, and 1.79, respectively, for background retinopathy and 2.92, 3.17, and 4.98, respectively, for proliferative retinopathy.

"Proliferative retinopathy in both sexes and background retinopathy in women predicted all-cause, CVD, and CHD death," the authors write. "These associations were independent of current smoking, hypertension, total cholesterol, HDL [high-density lipoprotein] cholesterol, glycemic control of diabetes, duration of diabetes, and proteinuria. This suggests the presence of common background pathways for diabetic microvascular and macrovascular disease other than those included in the conventional risk assessment of CVD."

The primary study limitation is evaluation of retinopathy based on fundoscopy, giving rise to the possibility that subtle changes may have been missed.

"A sex difference was observed in our study in the association of background retinopathy with all-cause, CVD, and CHD death, with a significant association in women but not in men," the authors conclude. "The sex difference observed in the association of background retinopathy with macrovascular disease warrants closer examination."

Take Away Info: In women with type 2 diabetes, background and proliferative retinopathy both predict all-cause, CVD, and CHD mortality, and the effect is seen within 10 years. In men with type 2 diabetes, only proliferative retinopathy predicts all-cause, CVD, and CHD mortality.

Diabetes Care. 2007;30:292-299.

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