Risk of retinopathy in women with pregnancy-induced hypertension: a nationwide population-based cohort study of 9-year follow-up after delivery.

BACKGROUND: The retina is potentially associated with several physiological, hormonal, and metabolic changes during pregnancy. The few available epidemiologic studies of ocular changes in pregnancy have mainly concerned retinopathies. Pregnancy-induced hypertension, which leads to ocular manifestations including blurred vision, photopsia, scotoma, and diplopia, might induce reactive changes in the retinal vessels. Although several studies have suggested the existence of pregnancy-induced hypertension-related retinal ocular disease, there are few large cohort studies on this topic. OBJECTIVE: This study aimed to investigate the risk of major retinal diseases including central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, and hypertensive retinopathy in the long-term postpartum stage according to the presence of previous pregnancy-induced hypertension in a large cohort based on the Korean National Health Insurance Database. STUDY DESIGN: On the basis of Korean health data, 909,520 patients who delivered from 2012 to 2013 were analyzed. Among them, patients who had previous ocular diseases or hypertension and multiple births were excluded. Finally, 858,057 mothers were assessed for central serous chorioretinopathy (ICD-10: H35.70), diabetic retinopathy (ICD-10: H36.0, E10.31, E10.32, E11.31, E11.32, E12.31, E13.31, E13.32, E14.31, E14.32), retinal vein occlusion (ICD-10: H34.8), retinal artery occlusion (ICD-10: H34.2), and hypertensive retinopathy (ICD-10: H35.02) for 9 years after delivery. Enrolled patients were divided into 2 groups: 10,808 patients with and 847,249 without pregnancy-induced hypertension. The primary outcomes were the incidence of central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, retinal artery occlusion, and hypertensive retinopathy 9 years after delivery. Clinical variables were age, parity, cesarean delivery, gestational diabetes mellitus, and postpartum hemorrhage. In addition, pregestational diabetes mellitus, kidney diseases, cerebrovascular diseases, and cardiovascular diseases were adjusted. RESULTS: Postpartum retinal disease during the 9 years after delivery and total retinal diseases showed higher rates in patients with pregnancy-induced hypertension. In detail, the rates of central serous chorioretinopathy (0.3% vs 0.1%), diabetic retinopathy (1.79% vs 0.5%), retinal vein occlusion (0.19% vs 0.1%), and hypertensive retinopathy (0.62% vs 0.05%) were higher than those found in patients without pregnancy-induced hypertension. After adjusting for confounding factors, pregnancy-induced hypertension was associated with development of postpartum retinopathy, with a >2-fold increase (hazard ratio, 2.845; 95% confidence interval, 2.54-3.188). Furthermore, pregnancy-induced hypertension affected the development of central serous chorioretinopathy (hazard ratio, 3.681; 95% confidence interval, 2.667-5.082), diabetic retinopathy (hazard ratio, 2.326; 95% confidence interval, 2.013-2.688), retinal vein occlusion (hazard ratio, 2.241; 95% confidence interval, 1.491-3.368), and hypertensive retinopathy (hazard ratio, 11.392; 95% confidence interval, 8.771-14.796) after delivery. CONCLUSION: A history of pregnancy-induced hypertension increases the risk of central serous chorioretinopathy, diabetic retinopathy, retinal vein occlusion, and hypertensive retinopathy according to 9-year long-term ophthalmologic follow-up.

Study of Characteristic Retinal Findings among Hypertensive Population Attending a Tertiary Care Hospital in Nepal.

Background Systemic hypertension is one of the most common chronic, debilitating diseases prevalent in the modern era, with many complications in terms of stroke, chronic kidney disease, coronary artery disease and retinopathy. When it comes to the eye, as a target organ damage, it leads to one of the many vision threatening conditions, hence degrading the quality of life. Early detection and subsequent management of patients at risk of hypertensive retinopathy serves to be a crucial panacea in the treatment course. Objective To investigate the characteristics retinal findings among hypertensive population and analyze the associated risk factors. Method A hospital based prospective study was conducted, among 250 patients presenting to ophthalmology outpatient department in Dhulikhel Hospital, Kathmandu University Hospital (DH-KUH), over a time span of 6 months, to analyze hypertensive retinopathy and its implications. Fundus examination under mydriasis was done on all subjects and hypertensive retinopathy was graded according to the modified Scheie classification. Result Most patients belonged to age group of 56-65 years (30%). Nearly half (48%, N=120) of the hypertensive population had some forms of retinopathy. Grade II hypertensive retinopathy (24.8%) was the most common hypertensive change observed. Majority (55%) of the patients with retinopathy were smokers. About two-third of the subjects (67.5%) had been diagnosed to have hypertension and under treatment for over 5 years. Conclusion The occurrence of retinopathy among hypertensive patients attending ophthalmology department is higher. Awareness regarding systemic hypertension and its effect on ocular health is very important to be disseminated among public. Timely referral among medical specialities could diagnose and prevent curable blindness among hypertensive patients.

Prevalence, Associated Factors and Awareness of Hypertensive Retinopathy among an Elderly Population with Hypertension in Nepal: The Bhaktapur Retina Study.

INTRODUCTION: Hypertensive retinopathy is a common complication in patients with hypertension. This study aims to assess the prevalence, associated factors and awareness of hypertensive retinopathy among an elderly population with hypertension in Bhaktapur, Nepal. MATERIALS AND METHODS: This is a population-based, cross-sectional study conducted from 2013 to 2015 in Bhaktapur district, Nepal. The sample size was 2100 subjects aged 60 years and above. From this sample, all diagnosed patients with hypertension were analyzed. A detailed history was obtained, and an ocular examination was performed. RESULTS: Information was complete for 1860 (88.57%) subjects. The age of the study population ranged from 60 to 95 years with the mean age of 69.64±7.31 years. Hypertension was found in 643 subjects (34.61%), of which 224 (12.04%) were newly diagnosed cases. Among the subjects with hypertension, hypertensive retinopathy was found in 81 cases (12.6%). Hypertensive retinopathy was more frequent in the age group 70-79 years (15.23%), males (13.25%), illiterates (13.56%), diabetics (16.49%), and body mass index (BMI) ≥25 kg/m2 (14%). None of the factors was found to be statistically significant. Among the study participants, awareness regarding the effect of hypertension on eye, retina and vision was found to be 13.84%, 8.4%, and 11.98% respectively. CONCLUSION: Prevalence of hypertension and hypertensive retinopathy among an elderly population of 60 years and above in Bhaktapur district, Nepal were similar to other countries. Hypertensive retinopathy was higher among males, illiterates, diabetes and BMI> 25kg/m2. Awareness of hypertensive retinopathy was 8.4% among hypertensive subjects. Emphasis should be directed toward improving awareness campaigns.

Obstructive sleep apnea, chronic obstructive pulmonary disease and hypertensive microvascular disease: a cross-sectional observational cohort study.

Hypertensive microvascular disease is associated with an increased risk of diastolic heart failure, vascular dementia and progressive renal impairment. This study examined whether individuals with obstructive sleep apnoea (OSA) had more retinal hypertensive microvascular disease than those with chronic obstructive pulmonary disease (COPD) and hospital controls. This was a single-centre, cross-sectional, observational study of participants recruited consecutively from a general respiratory clinic and a general medical clinic. OSA was diagnosed on overnight polysomnography study (apnoea:hypopnoea index ≥ 5), and controls with COPD had a forced expiratory volume/forced vital capacity (forced expiratory ratio) < 70%. Individuals with both OSA and COPD were excluded. Hospital controls had no COPD on respiratory function testing and no OSA on specialist physician questioning. Study participants completed a medical questionnaire, and underwent resting BP measurement, and retinal photography with a non-mydriatic camera. Images were deidentified and graded for microvascular retinopathy (Wong and Mitchell classification), and arteriole and venular calibre using a semiautomated method at a grading centre. Individuals with OSA (n = 79) demonstrated a trend to a higher mean arterial pressure than other hospital patients (n = 143) (89.2 ± 8.9 mmHg, p = 0.02), and more microvascular retinopathy (p < 0.001), and narrower retinal arterioles (134.2 ± 15.9 µm and 148.0 ± 16.2 µm respectively, p < 0.01). Microvascular retinopathy and arteriolar narrowing were still more common in OSA than hospital controls, after adjusting for age, BMI, mean arterial pressure, smoking history and dyslipidaemia (p < 0.01, p < 0.01, respectively). Individuals with OSA demonstrated a trend to a higher mean arterial pressure than those with COPD (n = 132, 93.2 ± 12.2 mmHg and 89.7 ± 12.8 mmHg respectively, p = 0.07), and more microvascular retinopathy (p = 0.0001) and narrower arterioles (134.2 ± 15.9 and 152.3 ± 16.8, p < 0.01). Individuals with OSA alone had more systemic microvascular disease than those with COPD alone or other hospital patients without OSA and COPD, despite being younger in age.

Hypertensive eye disease.

Hypertensive eye disease includes a spectrum of pathological changes, the most well known being hypertensive retinopathy. Other commonly involved parts of the eye in hypertension include the choroid and optic nerve, sometimes referred to as hypertensive choroidopathy and hypertensive optic neuropathy. Together, hypertensive eye disease develops in response to acute and/or chronic elevation of blood pressure. Major advances in research over the past three decades have greatly enhanced our understanding of the epidemiology, systemic associations and clinical implications of hypertensive eye disease, particularly hypertensive retinopathy. Traditionally diagnosed via a clinical funduscopic examination, but increasingly documented on digital retinal fundus photographs, hypertensive retinopathy has long been considered a marker of systemic target organ damage (for example, kidney disease) elsewhere in the body. Epidemiological studies indicate that hypertensive retinopathy signs are commonly seen in the general adult population, are associated with subclinical measures of vascular disease and predict risk of incident clinical cardiovascular events. New technologies, including development of non-invasive optical coherence tomography angiography, artificial intelligence and mobile ocular imaging instruments, have allowed further assessment and understanding of the ocular manifestations of hypertension and increase the potential that ocular imaging could be used for hypertension management and cardiovascular risk stratification.

Mild Hypertensive Retinopathy and Risk of Cardiovascular Disease: The Suita Study.

AIMS: This study aimed to investigate the association of mild hypertensive retinopathy with cardiovascular disease (CVD) risk. METHODS: A total of 7,027 residents aged 30-79 years without a history of CVD participated in the annual health checkups and retinal photography assessments. Retinal microvascular abnormalities were graded using the standard protocols and classified according to the Keith-Wagener-Barker classification. Mild hypertensive retinopathy was defined as grades 1 and 2. Cox proportional hazard model was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for total CVD and its subtypes according to the presence and absence of mild hypertensive retinopathy. RESULTS: During a median follow-up of 17 years, 351 incident stroke and 247 coronary heart disease (CHD) cases were diagnosed. After adjustment for traditional cardiovascular risk factors, mild hypertensive retinopathy was positively associated with risk of CVD (multivariable HR=1.24; 95% CI, 1.04-1.49) and stroke (1.28; 1.01-1.62) but not with risk of CHD (1.19; 0.89-1.58). Generalized arteriolar narrowing and enhanced arteriolar wall reflex were positively associated with CVD risk, the multivariable HR (95% CI) was 1.24 (1.00-1.54) and 1.33 (1.02-1.74), respectively. Moreover, mild hypertensive retinopathy was positively associated with stroke risk in normotensive participants. CONCLUSION: Mild hypertensive retinopathy was positively associated with CVD and stroke risk in the urban Japanese population. Especially, generalized arteriolar narrowing and enhanced arteriolar wall reflex were positively associated with CVD risk. These findings suggested that retinal photography could be helpful for cardiovascular risk stratification in the primary cardiovascular prevention.

Association between extremely high high-density lipoprotein-cholesterol and hypertensive retinopathy: results of a cross-sectional study from Kanagawa Investigation of Total Checkup Data from the National Database-6 (KITCHEN-6).

OBJECTIVES: Doubt has been cast on the atheroprotective effect of very high high-density lipoprotein cholesterol (HDL-C). Hypertensive retinopathy (HR) is caused by persistent systemic hypertension. Therefore, we aimed to investigate the association between extremely high HDL-C (EH-HDL) and HR. DESIGN: A cross-sectional study. PARTICIPANTS: A total of 4072 general Japanese population aged 40-74 years who underwent regular medical check-ups including fundus examinations. OUTCOME MEASURES: HR and clinical parameters including serum HDL-C were investigated. HR was determined by the Keith-Wagener classification and the Scheie classifications for Hypertension and Atherosclerosis (n=4054 available). Serum HDL-C was divided into five categories: 30-49, 50-69, 70-89, 90-109 and ≥110 mg/dL. RESULTS: Overall, 828 (20.3%) subjects had Keith-Wagener-HR, 578 (14.3%) had hypertension-HR, and 628 (15.5%) had atherosclerosis-HR. Blood pressure decreased as HDL-C level increased, whereas the prevalences of HRs showed U-shaped curves against HDL-C with minimum values for HDL-C 90-109 mg/dL. In logistic regression analyses, EH-HDL ≥110 mg/dL was significantly associated with Keith-Wagener-HR and atherosclerosis-HR, compared with HDL-C 90-109 mg/dL after adjustments for age, sex and systolic blood pressure (OR 3.01, 95% CI 1.45 to 6.27 and OR 2.23, 95% CI 1.03 to 4.86). The hypertension-HR was not significantly associated with EH-HDL regardless of adjustment for the confounding factors (p=0.05-0.08). Although serum HDL-C as a continuous variable was inversely associated with three HRs, which disappeared after adjustment for the confounding factors. CONCLUSION: EH-HDL may be associated with HR independently of blood pressure, suggesting that EH-HDL reflects a special atherosclerotic condition.

The relationship between Subfoveal Choroidal Thickness and Hypertensive Retinopathy.

The Beijing Eye Study 2011 is a population-based cross-sectional study in Northern China, which enrolled 3468 participants whose age were more than 50 years. A detailed ophthalmic examination was performed including spectral-domain optical coherence tomography with enhanced depth imaging for measurement of SFCT and fundus photography. Blood pressure, fundus photographs and choroidal OCT-images were available for 3237 (93.3%) subjects, with 1953 (56.3 ± 0.8%) of the study population fulfilled the diagnosis of hypertension and 1089 subjects having hypertensive retinopathy. For the hypertensive cases, the SFCT in patients with hypertensive retinopathy (286.48 ± 105.23 µm) was significantly thicker than subjects without hypertensive retinopathy (187.04 ± 78.80 µm, P < 0.001). SFCT was significantly associated with the stage of hypertensive retinopathy (P < 0.001), but not significantly associated with diastolic blood pressure (P = 0.94), history (P = 0.95) and years (P = 0.91) of hypertension. In conclusion, hypertension as systemic disease was not significantly affect the subfoveal choroidal thickness, but as ocular disease, hypertensive retinopathy was significantly related to changes of choroidal thickness. Lesions of choroid during chronic hypertension may play an important role in development of hypertensive retinopathy.

Association between Hyperhomocysteinemia and Hypertensive Retinopathy in a Chinese Han Population.

Purpose/aim: In some diseases, hyperhomocysteinemia (HHcy) has been recognized as a risk factor. However, information on the correlation between HHcy and hypertensive retinopathy (HR) in the Chinese population is unclear. We, therefore, aimed to investigate this association.Materials and Methods: A total of 382 patients were collected and 126 individuals were excluded in this study. Finally, 128 patients with HR and 128 control subjects were enrolled sequentially. The association between HHcy and the occurrence of HR was determined by multivariate logistic regression analysis, including interaction and stratified analyses.Results: HHcy, cardiovascular disease, fasting blood glucose, creatinine, triglyceride, diabetes, smoking habits, drinking habits were significantly associated with HR (P < .05) in the univariate logistic regression analysis. Each increase of 1 µmol/L of homocysteine concentration was significantly correlated with a 9% increased risk of HR (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.07-1.55, P < .05). Hierarchical analysis identified history of diabetes (OR = 7.38, P > .05), age ≥60 years (OR = 3.08, P > .05), male sex (OR = 1.04, P > .05), history of cardiovascular disease (OR = 7.88, P > .05), smoking habit (OR = 1.08, P > .05), and drinking habit (OR = 78.31, P > .05), as factors associated with HR, but not as independent risk factors for HR. Interaction analysis demonstrated no interaction between HHcy and HR.Conclusions: Within the Chinese Han population, HHcy is an independent risk factor for HR.

Positive relationship of hypertensive retinopathy with carotid intima--media thickness in hypertensive patients.

OBJECTIVES: We aimed to explore the relationship of hypertensive retinopathy with carotid intima--media thickness (CIMT), and to examine the possible effect modifiers in Chinese adults with hypertension. METHODS: We conducted a cross-sectional study of 12 342 hypertensive patients with complete exit site visit data from the China Stroke Primary Prevention Trial. CIMT was measured by carotid ultrasonography. Hypertensive retinopathy was diagnosed according to the Keith--Wagener--Barker classification. RESULTS: The mean (SD) CIMT among study participants was 739.9 (111.4) µm. Compared with patients with grade 1 hypertensive retinopathy or without hypertensive retinopathy, a significantly higher CIMT level (ß, 7.63, 95% CI: 2.54--12.73) was observed in patients with grade 2-4 hypertensive retinopathy. Moreover, the association between hypertensive retinopathy (grade 2-4 versus grade 1 or normal) and CIMT was stronger in participants of younger age (<60 years; ß, 13.70, 95% CI: 5.65--21.75; versus ≥60 years; ß, 1.03, 95% CI: -5.58 to 7.63; P interaction = 0.006); or with lower total homocysteine levels [<12.1 µmol/l (median); ß, 12.70, 95% CI: 5.98--19.42; versus ≥12.1 µmol/l; ß, 2.07, 95% CI: -5.63 to 9.78; P interaction = 0.030). None of the other variables, including sex, BMI, study centers, treatment group, SBP, triglycerides, total cholesterol, fasting blood glucose, folate, serum creatinine, current smoking and alcohol drinking, significantly modified the relation of hypertensive retinopathy with CIMT levels. CONCLUSION: Hypertensive retinopathy (grade 2 and higher) was significantly associated with increased CIMT in hypertensive patients. The association was stronger in those of younger age or with lower total homocysteine levels.

Why Miss the Chance? Incidental Findings while Telescreening for Diabetic Retinopathy.

PURPOSE: To report on incidental pathological findings met while screening for Diabetic Retinopathy (DR) in Diabetes Clinics (DC) by ophthalmologist-graded digital fundus imaging. METHODS: At the DC of Pescara (central Italy), for 3,859 eyes of 1,930 consecutive patients having not undergone fundus examination in the last year, two mydriatic fundus digital images, taken with a CenterVue DRS Digital Retinal Camera, were sent along with Best Corrected Visual Acuity, on a "store-and-forward" basis, to an ophthalmologist trained in DR screening, and graded according to the UK Diabetic Eye Screening Programme. Incidental fundus abnormalities other than DR were reported. RESULTS: No adverse event to mydriasis was reported. One hundred and eighty eyes (4.66%) were ungradable. Among the 3,679 gradable ones, 1,105 (30.04%) showed different degrees of DR (R1 to R3), and 126 (3.42%) maculopathy (M1). Any Age-Related Macular Degeneration was present in 387 eyes (10.52%), any optic disc and parapapillary area features suspect for glaucoma in 562 eyes (15.27%), any hypertensive retinopathy in 1,263 eyes (34.33%), vitreoretinal interface disease in 252 eyes (6.84%), myopic choroidopathy in 92 eyes (2.50%), disc pallor in 31 eyes (0.84%). Mean time was 5 min for screening, 2 min for grading. CONCLUSION: Teleretinography is a well-established, cost-effective procedure in DR screening. Along with increased attendance, locating a digital camera in a DC with a retina-specialist grader results in finding fundus pathologies also beyond DR, very similarly to fundus examination in an outpatient ophthalmic setting.

Hypertension in a resource-limited setting: Poor Outcomes on Short-term Follow-up in an Urban Hospital in Maputo, Mozambique.

Mozambique has low levels of detection, treatment, and control of hypertension. However, data on target organ damage and clinical outcomes are lacking. The authors aimed at characterizing the clinical profile, pattern of target organ damage, and short-term outcomes of patients referred to a first referral urban hospital in a low-income setting in Africa. We conducted a prospective descriptive cohort study from February 2016 to May 2017 in Maputo, Mozambique. Adult patients with systolic and diastolic blood pressure ≥180 mm Hg and/or ≥110 mm Hg, respectively, or any systolic blood pressure above 140 mm Hg and/or diastolic blood pressure above 90 mm Hg in the presence of target organ damage (with or without antihypertensive treatment) were submitted to detailed physical examination, funduscopy, laboratory profile, electrocardiography, and echocardiography. Six months after the occurrence of complications (stroke, heart failure, and renal failure), hospital admission and death were assessed. Overall, 116 hypertensive patients were recruited (mean age 57.5 ± 12.8 years old; 111[95.7%] black; 81[70%] female) of which 79 had severe hypertension. The baseline mean values recorded for systolic and diastolic blood pressure were 192.3 ± 23.6 and 104.2 ± 15.2 mm Hg, respectively. Most patients (93; 80.2%) were on antihypertensive treatment. Patients' risk profile revealed dyslipidemia, obesity, and diabetes in 59(54.1%), 48(42.5%), and 23(19.8%), respectively. Target organ damage was found in 111 patients. The commonest being left atrial enlargement 91(84.5%), left ventricular hypertrophy 57(50.4%), hypertensive retinopathy 30(26.3%), and chronic kidney disease 27(23.3%). Major events during 6-month follow-up were hospitalizations in 10.3% and death in 8.6% of the patients. Worsening of target organ damage occurred in 10 patients: four stroke, two heart failure, and four renal damage. Patients with severe hypertension and target organ damage were young with high-risk profile, low hypertension control, and high occurrence of complications during short-term follow-up. Efforts to improve high blood pressure control are needed to reduce premature mortality in this highly endemic poor setting.

Associations of Retinal Microvascular Diameters and Tortuosity With Blood Pressure and Arterial Stiffness: United Kingdom Biobank.

To examine the baseline associations of retinal vessel morphometry with blood pressure (BP) and arterial stiffness in United Kingdom Biobank. The United Kingdom Biobank included 68 550 participants aged 40 to 69 years who underwent nonmydriatic retinal imaging, BP, and arterial stiffness index assessment. A fully automated image analysis program (QUARTZ [Quantitative Analysis of Retinal Vessel Topology and Size]) provided measures of retinal vessel diameter and tortuosity. The associations between retinal vessel morphology and cardiovascular disease risk factors/outcomes were examined using multilevel linear regression to provide absolute differences in vessel diameter and percentage differences in tortuosity (allowing within person clustering), adjusted for age, sex, ethnicity, clinic, body mass index, smoking, and deprivation index. Greater arteriolar tortuosity was associated with higher systolic BP (relative increase, 1.2%; 95% CI, 0.9; 1.4% per 10 mmHg), higher mean arterial pressure, 1.3%; 0.9, 1.7% per 10 mmHg, and higher pulse pressure (PP, 1.8%; 1.4; 2.2% per 10 mmHg). Narrower arterioles were associated with higher systolic BP (-0.9 µm; -0.94, -0.87 µm per 10 mmHg), mean arterial pressure (-1.5 µm; -1.5, -1.5 µm per 10 mmHg), PP (-0.7 µm; -0.8, -0.7 µm per 10 mmHg), and arterial stiffness index (-0.12 µm; -0.14, -0.09 µm per ms/m2). Associations were in the same direction but marginally weaker for venular tortuosity and diameter. This study assessing the retinal microvasculature at scale has shown clear associations between retinal vessel morphometry, BP, and arterial stiffness index. These observations further our understanding of the preclinical disease processes and interplay between microvascular and macrovascular disease.

Association Of Hypertensive Retinopathy With Angiographic Severity Of Coronary Artery Disease Determined By Syntax Score.

BACKGROUND: Hypertension is a leading cause of morbidity among developing and developed countries. Hypertensive Retinopathy is a micro vascular complication of long standing hypertension while CAD is a macro vascular complication. The main objective of the study was to determine the association between worsening grade of hypertensive retinopathy with angiographic severity of coronary artery disease (CAD) measured by Syntax Score. METHODS: This was a cross sectional study which was conducted after approval from IRB. All patients with history of hypertension, who underwent coronary angiography, were included in the study. After a detailed history and physical exam, all included patients were subjected to fundoscopy. Patients were categorized into 4 groups according to Keith et al classification of hypertensive retinopathy: No HR, Mild HR, Moderate HR and Severe HR. Patients were also categorized into three groups on the basis of angiographic severity of CAD by syntax score (SS): Mild CAD (SS<22), Moderate CAD (SS: 22-32) and Severe CAD (SS>32). Data was analysed in SPSS Version 20.0. Categorical and continuous variables were described as frequencies/percentages and Mean±SD respectively. RESULTS: A total of 370 patients were included in the study out of which 205 were males with a mean age of 55.3±10.07 years. Mean duration of hypertension was 8.1±2.7 years with a mean SBP of 130.1±37.2 mmHg and mean DBP of 90.3±17.3 mmHg. Patients with no HR, mild HR, moderate HR and severe HR had a mean SS of 11.7±4.5, 17.1±3.9, 26.3±5.1 and 37.9±5.1 respectively. Significant association was found between HR and severity of CAD with a chi square value of 285.53 (p<0.001). PORs for worsening grade of HR with severity of CAD increased from 0.341 (p<0.001) for mild HR to 2.33 (p<0.001) times for severe HR. CONCLUSIONS: A higher grade of hypertensive retinopathy is significantly associated to a higher angiographic severity of CAD by syntax score.

Hypertensive Retinopathy: A Prognostic Factor for Morbidity and Mortality after Acute ST Elevation Myocardial Infarction.

OBJECTIVE: To determine the association between hypertensive retinopathy (HR) and post ST elevation myocardial infarction (STEMI) complications among successfully thrombolysed patients. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Cardiology Unit, Lady Reading Hospital, Peshawar, from June 2016 to December 2017. METHODOLOGY: Patients with history of hypertension for at least 5 years who presented with STEMI and were successfully thrombolysed, were included. On the basis of fundoscopy, patients were grouped into no, mild, moderate, and severe hypertensive retinopathy. Primary and secondary endpoints included a composite of death, re-MI, stroke, re-hospitalisation secondary to left ventricular failure, cardiogenic shock, arrhythmia, heart block, and ventricular septal rupture at 30 days and 4 months, respectively. Association between hypertensive retinopathy and post STEMI complications was determined by Chi-square test. Regression model was used to calculate relative risk of complications with hypertensive retinopathy. P <0.05 was taken as significant. RESULTS: A total of 118 patients with a mean age of 54.83 ±8.6 years were included in the study. Of these, 49.2% (n=58) were males. Moreover, 38.1% (n=45) of patients were grouped under no HR, 22.8% (n=27) under mild HR, 21.1% (n=25) and 17.7% (n=21) under moderate and severe HR, respectively. Primary endpoints achieved were 0% in no HR group and 19% in severe HR group x² = 18.1, p <0.001). Secondary endpoints were achieved in 2.2% in no HR group and 40.7%, 56% and 100% in mild, moderate and severe HR group, respectively, ( x² = 81.1, p <0.001). HR also increased the relative risk of complications by 3.17 times (p <0.001) and death by 1.75 times (p <0.001). CONCLUSION: Hypertensive retinopathy is an independent risk factor for post-acute STEMI complications in successfully thrombolysed patients and increased the relative risk for complications by 3.17 times.

Retinal imaging to identify target organ damage in older Africans: A pilot study.

By 2030, sub-Saharan Africa is forecast to see the steepest rise in the number of people with hypertension of any world region. Hypertensive retinopathy is known to be a common complication of hypertension in developed countries and some studies suggest it is associated with the presence of other hypertension-related end-organ damage (EOD) such as stroke and cardiovascular disease. In Tanzania hypertension is relatively more common than in other parts of sub-Saharan Africa, especially in the older population; however, the prevalence of hypertensive retinopathy and its association with EOD remain unknown. The authors conducted a cross-sectional study of elderly, community-dwelling, rural Tanzanians to determine the prevalence of hypertensive retinopathy and its association with hypertension and other forms of EOD. Hypertensive retinopathy was diagnosed based on retinal imaging. In a cohort of 61 patients with gradable images, the authors found the overall prevalence of hypertensive retinopathy to be 64% (n = 39), which was strongly associated with hypertension (X2 [1] = 4.207, P = .004), with a significant trend towards more severe retinopathy with more severe hypertension (r = .377, P = .003). The authors did not find hypertensive retinopathy to be associated with other forms of EOD. Hypertensive retinopathy is highly prevalent in this population and is associated in most but not all cases with hypertension. These findings do not suggest that it could be used as a screening tool for EOD, but it is important to identify and educate patients with retinopathy about possible complications of the condition.

Relationship between nocturnal blood pressure profiles and the presence and severity of hypertensive retinopathy. / Relação entre o perfil tensional noturno e a prevalência e gravidade da retinopatia hipertensiva.

INTRODUCTION: Non-dipper and extreme dipper blood pressure (BP) profiles are associated with a worse cardiovascular prognosis. The relationship between nocturnal BP profile and hypertensive retinopathy (HR) is not fully established. AIM: To assess the association between the prevalence and severity of HR and nocturnal BP. METHODS: We prospectively studied hypertensive patients who underwent 24-hour ambulatory BP monitoring. The population was divided into two groups according to the presence or absence of lesions and compared according to baseline characteristics, nocturnal BP profile (dippers, non-dippers, inverted dippers/risers and extreme dippers) and mean nocturnal systolic (SBP) and diastolic (DBP) BP values. The presence and severity of HR were assessed using the Scheie classification. The relationship between nocturnal SBP and DBP values (and nocturnal BP profile) and the prevalence and severity of HR was determined. RESULTS: Forty-six patients (46% male, aged 63±12 years) were analyzed, of whom 91% (n=42) were under antihypertensive treatment. Seventy percent (n=33) had uncontrolled BP. HR was diagnosed in 83% (n=38). Patients with HR had higher mean systolic nocturnal BP (151±23 vs. 130±13 mmHg), p=0.008). Patients with greater HR severity (Scheie stage ≥2) had higher nocturnal BP (153±25 vs. 140±16 mmHg, p=0.04). There was no statistically significant association between DBP and nocturnal BP patterns and HR. CONCLUSIONS: The prevalence and severity of HR were associated with higher nocturnal SBP. No relationship was observed between nocturnal BP profile and the presence of HR.

A 10-year monitoring of the eyesight in patients after kidney transplantation.

A pilot study of a 10-year analysis of the eyesight characteristics in patients after renal transplantation with a view to a later wider study of the same population.The study encompassed 50 eyes in 25 patients who underwent renal transplantation in the years 2007 and 2008. All patients underwent: visual acuity measurement, tonometry, slit lamp examination, and spectroscopic optical coherence tomography.Changes in the eyes observed during the 10-year observation period included mostly: cataract (48%), hypertensive angiopathy (28%), diabetic macular edema (16%), and glaucoma (16%). Ten years after the renal transplant visual acuity declined in 15 patients (60%). In 67% of those with eyesight deterioration the cause was cataract, while in patients with no changes in the eyesight (n = 10) cataract was diagnosed only in one. Patients with cataracts had been more often treated with cyclosporine, and that difference was statistically significant (73% vs 21%; P < .05). Comparing patients with hypertensive angiopathy with controls has shown that in the first group creatinine levels were statistically significantly higher (1.6 vs 1.16 mg/dL; P < .05). Patients with angiopathy had been also longer on renal replacement therapy before transplant (57 vs 26 months, P > .05), and this group included also statistically more persons after retransplantation (43% vs 5%, P < .05).Most frequent ophthalmological diagnoses in patients after a kidney transplant include cataract, diabetic retinopathy, and hypertensive angiopathy. Visual acuity deterioration was seen in 60% of patients and was mainly the effect of cataract progress. The effect of cyclosporine on cataract progress was significant. The diagnosis of hypertensive angiopathy corresponded with poorer function of the transplanted kidney.

Prevalence and clinical spectrum of hypertensive retinopathy among hypertension clinic patients at Queen Elizabeth Central Hospital in Malawi.

Background: Prevalence and spectrum of hypertensive retinopathy in the population reflects the status of hypertension control and the associated risks for cardiovascular events. We investigated the prevalence and clinical spectrum of hypertensive retinopathy among patients attending hypertension clinic at a tertiary hospital in Malawi. Methods: This was a cross-sectional study of systematically selected patients attending hypertension clinic at Queen Elizabeth Central Hospital. Patient interviews using a structured questionnaire and review of patients' medical records (health passports) were done to obtain the following information: demographics, duration since the diagnosis of hypertension, history of stroke and blood pressure measurements. The presence and severity of hypertensive retinopathy was determined by dilated fundoscopy through slit lamp biomicroscopy. Results: We recruited 104 patients. Women outnumbered men by 3:1. Women tended to be younger compared to men (mean ages 54 and 61 years respectively). Of the surveyed patients, 80% had sub-optimal blood pressure control and 75% had evidence of hypertensive retinopathy. History of stroke was associated with hypertensive retinopathy. Conclusions: Hypertensive retinopathy is very common in patients attending the hypertension clinic at Queen Elizabeth Central Hospital in Blantyre, Malawi. This may be a reflection of sub-optimal blood pressure control in this patient population. There is a need to identify the actual reasons, rectify them and intensify intervention in control of hypertension in this patient population.

Retinopathy and left ventricular hypertrophy in patients with chronic kidney disease: Interrelationship and impact on clinical outcomes.

BACKGROUND: Retinopathy and left ventricular hypertrophy (LVH) are representative markers of microvascular and cardiac dysfunction in patients with chronic kidney disease (CKD). However, their relationship and their combined effects on clinical outcomes are unknown. METHODS: We included 401 patients with nondialysis-dependent CKD stage 3-5 who had been examined with fundus photography for diabetic or hypertensive retinopathy. The presence of LVH was identified by echocardiography. The clinical significance of retinopathy and LVH was evaluated in terms of the rate of renal function decline and for any cardiovascular event (CVE)/death. RESULTS: CKD patients with retinopathy had a higher prevalence of LVH than those without retinopathy (38.9% vs. 27.6%, P=0.017). The presence of retinopathy was independently associated with LVH (odds ratio 1.69, 95% confidence interval [CI] 1.02, 2.80). Compared with subjects without either retinopathy or LVH, the coexistence of retinopathy and LVH was independently associated with rapid renal function decline (ß=-3.28; 95% CI -6.52, -0.04), whereas retinopathy or LVH alone were not. Patients with both retinopathy and LVH had a higher risk of CVE/death (adjusted hazard ratio 2.75; 95% CI 1.44, 5.26) than patients with either factor alone. A significant synergistic interaction was observed between retinopathy and LVH to predict CVE/death (P for interaction=0.049). CONCLUSIONS: Retinopathy was independently associated with LVH. The coexistence of retinopathy and LVH was associated with higher risks of CKD progression and CVE/death than was either factor alone, and their combined effects synergized to predict the risk of CVE/death.