Index
Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with diabetes. Diabetic retinopathy (DR), which is a common microvascular complication of diabetes, is a leading cause of blindness in working-age adults. Beyond the eye, retinopathy changes in diabetic patients have been shown to carry an increased risk for cardiovascular events including coronary heart disease, heart failure, stroke, all-cause and CVD mortality. In addition to clinical CVD, DR has also been shown to be associated with subclinical measures of atherosclerosis. Independent of diabetes, chronic kidney disease (CKD) is a major risk factor for CVD and death due to CVD accounts for up to 50% of all deaths in patients with moderate and severe CKD. DR is a well-known risk factor for CKD. DR shares many risk factors, genetic and pathogenic pathways with heart, brain and kidney and a simple non-invasive assessment of DR could improve risk stratification of CVD, in particular in those with diabetes. In the last 5 years, advances in artificial-intelligence based deep learning and computer vision have opened new possibilities of using retinal images to predict DR with accuracy comparable to that of human experts and other systemic diseases including stroke, and dementia. Poplin et al. in a recent study demonstrated the application of retinal image-based deep learning algorithms to predict cardiovascular risk factors. While the impact of DR on vision is well known, its many associations with clinical and subclinical CVD are less recognized. In this book, we comprehensively reviewed the epidemiological evidence and pathogenic links of DR to various cardiovascular events and implications for assessment of retina in cardiovascular risk prediction. The book comprises 10 chapters:
1Cardiovascular disease risk in diabetes mellitus
2Epidemiology and risk factors for diabetic retinopathy
3Diabetic retinopathy and stroke
4Diabetic retinopathy and heart disease
5Diabetic retinopathy and chronic kidney disease
6Diabetic retinopathy and mortality
7Retinal vascular changes in diabetes and dementia
8Anti-vascular endothelial growth factor therapy and CVD risk
9Novel retinal imaging in assessment of cardiovascular risk factors and diseases
10Reducing cardiovascular risk in diabetes: Insights from diabetes trials
Starting with overview of CVD risk in diabetes, the book covers in detail the links of DR with each of the CVD outcome including stroke, coronary artery disease, heart failure, CKD, dementia and mortality and the usefulness of DR in CVD risk prediction. Antiangiogenic therapy using anti-vascular endothelial growth factor (anti-VEGF) is the standard care for the treatment of diabetic macular oedema. However, concerns about their safety have been raised, since diabetic patients are at increased risk for cardiovascular events and systemic adverse events such as arterial thromboembolic events due to VEGF inhibition. To address this concern, a separate chapter is dedicated to reviewing the current evidence from clinical trials on cardiovascular safety of anti-VEGF therapy in diabetic patients treated for diabetic macular oedema. The book also highlights the potential of novel retinal imaging to predict CVD and its risk factors using the state-of-the art artificial intelligence-based deep learning systems. The last chapter provides insights from contemporary diabetic trials that demonstrated the enhanced cardiovascular benefit of novel glucose lowering therapy.
Authors who contributed to book chapters are expert researchers in their individual fields, many of whom are leading international authorities. We hope this book will be an invaluable resource for specialists translating research findings into clinical care including those in cardiology, endocrinology, ophthalmology, general practitioners, and public health practitioners, researchers, graduate students, as well as biotech companies interested in developing retinal image-based diagnostic and prognostic tools.
Charumathi Sabanayagam, Singapore
Tien Y. Wong, Singapore
Sabanayagam C, Wong TY (eds): Diabetic Retinopathy and Cardiovascular Disease.
Front Diabetes. Basel, Karger, 2019, vol 27, pp 1–19 (DOI: 10.1159/000486261)
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Cardiovascular Disease Risk in Diabetes Mellitus
Matthew J.L. Harea–c Jonathan E. Shawd–f
aDiabetes and Vascular Medicine Unit, Monash Health, Melbourne, VIC, Australia; bMenzies School of Health Research, Darwin, NT, Australia; cDepartment of Endocrinology, Royal Darwin Hospital, Darwin, NT, Australia; dClinical and Population Health, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; eSchool of Life Sciences, La Trobe University, Melbourne, VIC, Australia; fSchool of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Abstract
Cardiovascular disease is the leading cause of mortality and morbidity among people with diabetes mellitus. The epidemic of diabetes continues to contribute significantly to the global burden of cardiovascular disease with varying epidemiological trends in different regions and resource settings. Understanding and estimating cardiovascular risk is an essential component of diabetes care. Increasingly, assessment of absolute cardiovascular risk in individuals with diabetes is used to guide treatment targets and medical therapies. Numerous approaches to assessing cardiovascular risk in diabetes have been developed. These largely rely on traditional risk factor associations, but there is substantial ongoing research into novel biomarkers and genetics. This chapter provides an overview of cardiovascular risk in diabetes, including epidemiology, mechanisms and a particular focus on risk prediction.
© 2019 S. Karger AG, Basel
Introduction
The burden of non-communicable diseases has been recognised by world leaders as a major public health challenge that undermines social and economic development [1]. Six of the top ten causes of death globally are now non-communicable diseases (Fig. 1). Cardiovascular diseases, including ischaemic heart disease and stroke, are the leading causes of death, even in low- and middle-income countries [2]. In 2015, the United Nations adopted the 2030 Agenda for Sustainable Development, which included a target to reduce by one third premature mortality from non-communicable diseases through prevention and treatment [3]. Thorough understanding of determinants and predictors of cardiovascular disease, particularly in high-risk individuals, is of great importance. The epidemic of diabetes mellitus is a significant contributor to the global burden of cardiovascular disease. Diabetes confers an approximate doubling of the risk of coronary disease, stroke and death due to vascular causes, and it is estimated that 10% of vascular deaths in developed countries are attributable to diabetes [4].
