title: Diabetic retinopathy, its progression, and incident cardiovascular events in the ACCORD trial.
abstract: OBJECTIVE
  Both the presence of diabetic retinopathy and its severity are significantly associated with future cardiovascular (CV) events. Whether its progression is also linked to incident CV outcomes hasn't been assessed.
  
  
  METHODS
  The relationship between retinopathy, its 4-year progression, and CV outcomes (CV death or nonfatal myocardial infarction or stroke) was analyzed in participants in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial who also participated in the ACCORD Eye Study. Retinopathy was classified as either none, mild, moderate, or severe, and worsening was classified as a <2-step, 2-3-step, or >3-step change (that included incident laser therapy or vitrectomy).
  
  
  RESULTS
  Participants (n = 3,433) of mean age 61 years had baseline retinal photographs (seven stereoscopic fields). Compared with no retinopathy, the adjusted HRs (95% CI) for the CV outcome rose from 1.49 (1.12-1.97) for mild retinopathy to 2.35 (1.47-3.76) for severe retinopathy. A subset of 2,856 was evaluated for progression of diabetic retinopathy at 4 years. The hazard of the primary outcome increased by 38% (1.38 [1.10-1.74]) for every category of change in retinopathy severity. Additional adjustment for the baseline and follow-up levels of A1C, systolic blood pressure, and lipids either individually or together rendered the relationships between worsening and CV outcomes nonsignificant.
  
  
  CONCLUSIONS
  Both the severity of retinopathy and its progression are determinants of incident CV outcomes. The retina may provide an anatomical index of the effect of metabolic and hemodynamic factors on future CV outcomes.
authors.affiliation: Department of Medicine, McMaster University, Hamilton, Ontario, Canada. gerstein@mcmaster.ca
authors.forename: Hertzel C
authors.initials: HC
authors.lastname: Gerstein
authors.forename: Walter T
authors.initials: WT
authors.lastname: Ambrosius
authors.forename: Ronald
authors.initials: R
authors.lastname: Danis
authors.forename: Faramarz
authors.initials: F
authors.lastname: Ismail-Beigi
authors.forename: William
authors.initials: W
authors.lastname: Cushman
authors.forename: Jorge
authors.initials: J
authors.lastname: Calles
authors.forename: Maryann
authors.initials: M
authors.lastname: Banerji
authors.forename: Ulrich
authors.initials: U
authors.lastname: Schubart
authors.forename: Emily Y
authors.initials: EY
authors.lastname: Chew
mesh_terms: D000368:Aged; D002318:Cardiovascular Diseases / Q000453:epidemiology*; D003930:Diabetic Retinopathy / Q000150:complications / Q000453:epidemiology* / Q000473:pathology*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012307:Risk Factors