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Meta-analysis: Retinal Vessel Caliber and Risk for Coronary Heart Disease

Kevin McGeechan, MBiostat; Gerald Liew, MBBS, MMed; Petra Macaskill, PhD; Les Irwig, MBBCh, PhD; Ronald Klein, MD, MPH; Barbara E.K. Klein, MD, MPH; Jie Jin Wang, MMed, PhD; Paul Mitchell, MD, PhD; Johannes R. Vingerling, MD, PhD; Paulus T.V.M. deJong, MD, PhD; Jacqueline C.M. Witteman, PhD; Monique M.B. Breteler, MD, PhD; Jonathan Shaw, MD; Paul Zimmet, MD; and Tien Y. Wong, MD, PhD
[+] Article, Author, and Disclosure Information

From University of Sydney, Sydney, New South Wales, Australia; University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin; Erasmus Medical Center, Rotterdam, the Netherlands; Baker IDI Heart and Diabetes Institute and University of Melbourne, Melbourne, Victoria, Australia; Singapore Eye Research Institute and National University of Singapore, Kent Ridge, Singapore; and Royal Netherlands Academy of Arts and Sciences and Academic Medical Center, Amsterdam, the Netherlands.

Note: A full list of principal CHS investigators and institutions can be found at www.chs-nhlbi.org/pi.htm.

Acknowledgment: The authors thank Ruth Mitchell, Trials Search Co-ordinator, Cochrane Renal Group, Centre for Kidney Research, Children's Hospital at Westmead, Australia, for her advice on the construction of the MEDLINE and EMBASE search strategies. The authors also thank the staff and participants of the ARIC Study for their important contributions.

Grant Support: By the Australian National Health and Medical Research Council (program grants 402764 and 358395) and the National Heart, Lung, and Blood Institute (contracts N01-HC-85079 through N01-HC-85086, N01-HC-35129, N01 HC-15103, N01 HC-55222, N01-HC-75150, and N01-HC-45133 and grant U01 HL080295), with additional contributions from the National Institute of Neurological Disorders and Stroke. The ARIC Study is carried out as a collaborative study supported by National Heart, Lung, and Blood Institute contracts N01-HC-55015, N01-HC-55016, N01-HC-55018, N01-HC-55019, N01-HC-55020, N01-HC-55021, and N01-HC-55022.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Tien Y. Wong, MD, PhD, Singapore Eye Research Institute, National University of Singapore, 11 Third Hospital Avenue, Singapore 168751, Singapore; e-mail, ophwty@nus.edu.sg.

Current Author Addresses: Mr. McGeechan and Drs. Macaskill and Irwig: School of Public Health, Edward Ford Building (A27), The University of Sydney, New South Wales 2006, Australia.

Drs. Liew, Wang, and Mitchell: Centre for Vision Research, Department of Ophthalmology, University of Sydney, Westmead Hospital, Hawkesbury Road, Westmead, New South Wales 2145, Australia.

Drs. R. Klein and B. Klein: University of Wisconsin–Madison, Department of Ophthalmology and Visual Sciences, 610 North Walnut Street, Madison, WI 53726.

Drs. Vingerling, Witteman, and Breteler: Department of Epidemiology and Biostatistics, Erasmus Medical Center, Postbus 2040, 3000CA Rotterdam, Netherlands.

Dr. deJong: Department of Ophthalmology, Erasmus Medical Center, Postbus 2040, 3000CA Rotterdam, Netherlands.

Drs. Shaw and Zimmet: Baker IDI Heart and Diabetes Institute, Box 6492, Saint Kilda Road Central, Victoria 8008, Australia.

Dr. Wong: Singapore Eye Research Institute, National University of Singapore, 11 Third Hospital Avenue, Singapore 168751, Singapore.

Ann Intern Med. 2009;151(6):404-413. doi:10.7326/0003-4819-151-6-200909150-00005
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Background: Retinal vessel caliber may be a novel marker of coronary heart disease (CHD) risk. However, the sex-specific effect, magnitude of association, and effect independent of traditional CHD disease risk factors remain unclear.

Purpose: To determine the association between retinal vessel caliber and risk for CHD.

Data Sources: Relevant studies in any language identified through MEDLINE (1950 to June 2009) and EMBASE (1950 to June 2009) databases.

Study Selection: Studies were included if they examined a general population, measured retinal vessel caliber from retinal photographs, and documented CHD risk factors and incident CHD events.

Data Extraction: 6 population-based prospective cohort studies provided data for individual participant meta-analysis.

Data Synthesis: Proportional hazards models, adjusted for traditional CHD risk factors, were constructed for retinal vessel caliber and incident CHD in women and men. Among 22 159 participants who were free of CHD and followed for 5 to 14 years, 2219 (10.0%) incident CHD events occurred. Retinal vessel caliber changes (wider venules and narrower arterioles) were each associated with an increased risk for CHD in women (pooled multivariable-adjusted hazard ratios, 1.16 [95% CI, 1.06 to 1.26] per 20-μm increase in venular caliber and 1.17 [CI, 1.07 to 1.28] per 20-μm decrease in arteriolar caliber) but not in men (1.02 [CI, 0.94 to 1.10] per 20-μm increase in venular caliber and 1.02 [CI, 0.95 to 1.10] per 20-μm decrease in arteriolar caliber). Women without hypertension or diabetes had higher hazard ratios.

Limitation: Error in the measurement of retinal vessel caliber and Framingham variables was not taken into account.

Conclusion: Retinal vessel caliber changes were independently associated with an increased risk for CHD events in women.


Grahic Jump Location
Figure 1.
Literature search and selection.

CHD = coronary heart disease.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Forest plots of the adjusted hazard ratios for coronary heart disease events.

ARIC = Atherosclerosis Risk in Communities; AusDiab = Australian Diabetes, Obesity and Lifestyle; BDES = Beaver Dam Eye Study; BMES = Blue Mountains Eye Study; CHS = Cardiovascular Health Study; RS = Rotterdam Study. Plots are adjusted for age, systolic blood pressure, diastolic blood pressure, presence of diabetes, body mass index, serum cholesterol level, serum high-density lipoprotein cholesterol level, current smoking status, current use of antihypertensive medication, and the other retinal vessel caliber. Top. Ratios per 20-μm decrease in retinal arteriolar caliber. Bottom. Ratios per 20-μm increase in retinal venular caliber.

Grahic Jump Location




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Retinal changes can predict both acute and chronic coronary artery disease
Posted on September 26, 2009
Ghanshyam Palamaner Subash Shantha
Sri Ramachandra University, Chennai, India
Conflict of Interest: None Declared

We read with interest the review article by McGeechan et al. (1). From this prospective study they concluded that retinal vessel caliber changes were independently associated with an increased risk for CHD events in women. We recently concluded a cross-sectional study where we analyzed the utility of hypertensive retinal changes in predicting coronary artery disease among elderly hypertensive patients (aged > 65years) who presented to the emergency room with unstable angina (2). Hypertensive retinal changes had a likelihood ratio of a positive test (LR+) and likelihood ratio of negative test (LR-) of 3.92 and 0.52 respectively in predicting coronary artery disease. Hence we concluded that hypertensive retinal changes had a moderate accuracy in predicting coronary artery disease and hence can be used as a cost effective screening tool. We thought we will share our experience just to emphasize the point that retinal examination should be made mandatory in the assessment of hypertensive patients. They are useful in the assessment of both acute and chronic CHD.


1) McGeechan K, Liew G, Macaskill P, Irwig L, Klein R, Klein BE, Wang JJ, Mitchell P, Vingerling JR, Dejong PT, Witteman JC, Breteler MM, Shaw J, Zimmet P, Wong TY. Meta-analysis: retinal vessel caliber and risk for coronary heart disease. Ann Intern Med. 2009; 151(6):404-13.

2) Shantha GP, Srinivasan Y, Kumar AA, Salim S, Prabakhar S, Rajan AG, Muralidharan TR, Can retinal changes predict coronary artery disease in elderly hypertensives presenting with angina. American Journal of Emergency Medicine, In press.

Conflict of Interest:

None declared

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