Diabetic Retinopathy and the Risk of Coronary Heart Disease

The Atherosclerosis Risk in Communities Study

  1. Ning Cheung, MBBS1,
  2. Jie Jin Wang, PHD12,
  3. Ronald Klein, MD, MPH3,
  4. David J. Couper, PHD4,
  5. A. Richey Sharrett, MD, DRPH5 and
  6. Tien Y. Wong, MBBS, PHD16
  1. 1Centre for Eye Research Australia, University of Melbourne, Victoria, Australia
  2. 2Centre for Vision Research, University of Sydney, Sydney, Australia
  3. 3Department of Ophthalmology and Visual Science, University of Wisconsin, Madison, Wisconsin
  4. 4Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina
  5. 5Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
  6. 6Singapore Eye Research Institute, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  1. Address correspondence and reprint requests to Tien Y. Wong, MD, PhD, Centre for Eye Research Australia, University of Melbourne, 32 Gisborne St., Victoria 3002, Australia. E-mail: twong{at}


OBJECTIVE— We sought to examine the relation of diabetic retinopathy to incident coronary heart disease (CHD).

RESEARCH DESIGN AND METHODS— A population-based, prospective cohort study consisting of 1,524 middle-aged individuals with type 2 diabetes without prevalent CHD and stroke at baseline was conducted. Diabetic retinopathy signs were graded from retinal photographs according to the Early Treatment for Diabetic Retinopathy Study severity scale. Incident CHD events (myocardial infarction, fatal CHD, or coronary revascularization) were identified and validated following standardized protocols.

RESULTS— In our study, 214 (14.7%) participants had diabetic retinopathy. Over an average follow-up of 7.8 years, there were 209 (13.7%) incident CHD events. After controlling for age, sex, race, study center, fasting glucose, A1C, duration of diabetes, blood pressure, antihypertensive treatment, cigarette smoking, BMI, and lipid profile, the presence of diabetic retinopathy was associated with a twofold higher risk of incident CHD events (hazard rate ratio [HR] 2.07 [95% CI 1.38–3.11]) and a threefold higher risk of fatal CHD (3.35 [1.40–8.01]). Further adjustments for inflammatory markers, carotid artery intima-media thickness, or nephropathy had minimal impact on the association. The increased risk of CHD was significant in both men (1.89 [1.08–3.31]) and women (2.16 [1.16–4.02]) with diabetic retinopathy.

CONCLUSIONS— In individuals with type 2 diabetes, the presence of retinopathy signifies an increased CHD risk, independent of known risk factors. Our data support the role of microvascular disease in the pathogenesis of CHD in diabetes.


  • Published ahead of print at on 26 March 2007. DOI: 10.2337/dc07-0264.

    A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.

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    • Accepted March 15, 2007.
    • Received February 8, 2007.
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  1. Diabetes Care vol. 30 no. 7 1742-1746
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