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Chew EY, Burns SA, Abraham AG, Bakhoum MF, Beckman JA, Chui TYP, Finger RP, Frangi AF, Gottesman RF, Grant MB, Hanssen H, Lee CS, Meyer ML, Rizzoni D, Rudnicka AR, Schuman JS, Seidelmann SB, Tang WHW, Adhikari BB, Danthi N, Hong Y, Reid D, Shen GL, Oh YS. Standardization and clinical applications of retinal imaging biomarkers for cardiovascular disease: a Roadmap from an NHLBI workshop. Nat Rev Cardiol 2024:10.1038/s41569-024-01060-8. [PMID: 39039178 DOI: 10.1038/s41569-024-01060-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/24/2024]
Abstract
The accessibility of the retina with the use of non-invasive and relatively low-cost ophthalmic imaging techniques and analytics provides a unique opportunity to improve the detection, diagnosis and monitoring of systemic diseases. The National Heart, Lung, and Blood Institute conducted a workshop in October 2022 to examine this concept. On the basis of the discussions at that workshop, this Roadmap describes current knowledge gaps and new research opportunities to evaluate the relationships between the eye (in particular, retinal biomarkers) and the risk of cardiovascular diseases, including coronary artery disease, heart failure, stroke, hypertension and vascular dementia. Identified gaps include the need to simplify and standardize the capture of high-quality images of the eye by non-ophthalmic health workers and to conduct longitudinal studies using multidisciplinary networks of diverse at-risk populations with improved implementation and methods to protect participant and dataset privacy. Other gaps include improving the measurement of structural and functional retinal biomarkers, determining the relationship between microvascular and macrovascular risk factors, improving multimodal imaging 'pipelines', and integrating advanced imaging with 'omics', lifestyle factors, primary care data and radiological reports, by using artificial intelligence technology to improve the identification of individual-level risk. Future research on retinal microvascular disease and retinal biomarkers might additionally provide insights into the temporal development of microvascular disease across other systemic vascular beds.
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Affiliation(s)
- Emily Y Chew
- Division of Epidemiology and Clinical Applications, National Eye Institute, NIH, Bethesda, MD, USA.
| | - Stephen A Burns
- School of Optometry, Indiana University, Bloomington, IN, USA
| | - Alison G Abraham
- Department of Epidemiology, Colorado School of Public Health, University of Colorado, Aurora, CO, USA
| | - Mathieu F Bakhoum
- Departments of Ophthalmology and Visual Science and Pathology, School of Medicine, Yale University, New Haven, CT, USA
| | - Joshua A Beckman
- Division of Vascular Medicine, University of Southwestern Medical Center, Dallas, TX, USA
| | - Toco Y P Chui
- Department of Ophthalmology, New York Eye and Ear Infirmary of Mount Sinai, New York, NY, USA
| | - Robert P Finger
- Department of Ophthalmology, Mannheim Medical Faculty, University of Heidelberg, Mannheim, Germany
| | - Alejandro F Frangi
- Division of Informatics, Imaging and Data Science (School of Health Sciences), Department of Computer Science (School of Engineering), University of Manchester, Manchester, UK
- Alan Turing Institute, London, UK
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke, NIH, Bethesda, MD, USA
| | - Maria B Grant
- Department of Ophthalmology and Visual Sciences, School of Medicine, University of Alabama Heersink School of Medicine, Birmingham, AL, USA
| | - Henner Hanssen
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Cecilia S Lee
- Department of Ophthalmology, University of Washington, Seattle, WA, USA
| | - Michelle L Meyer
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Damiano Rizzoni
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Alicja R Rudnicka
- Population Health Research Institute, St. George's University of London, London, UK
| | - Joel S Schuman
- Wills Eye Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Sara B Seidelmann
- Department of Clinical Medicine, Columbia College of Physicians and Surgeons, Greenwich, CT, USA
| | - W H Wilson Tang
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bishow B Adhikari
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Narasimhan Danthi
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Yuling Hong
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Diane Reid
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
| | - Grace L Shen
- Retinal Diseases Program, Division of Extramural Science Programs, National Eye Institute, NIH, Bethesda, MD, USA
| | - Young S Oh
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, NIH, Bethesda, MD, USA
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2
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Günthner R, Lorenz G, Braunisch MC, Angermann S, Matschkal J, Hausinger R, Kuchler T, Glaser P, Schicktanz F, Haller B, Heemann U, Streese L, Hanssen H, Kotliar K, Schmaderer C. Endothelial dysfunction in retinal vessels of hemodialysis patients compared to healthy controls. Sci Rep 2024; 14:13948. [PMID: 38886448 PMCID: PMC11183144 DOI: 10.1038/s41598-024-64581-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 06/11/2024] [Indexed: 06/20/2024] Open
Abstract
Endothelial dysfunction is a key factor promoting atherosclerosis and cardiovascular complications. Hemodialysis patients typically show various cardiovascular complications and impaired retinal venular dilation has been described as a risk factor for mortality. Non-invasive retinal vessel analysis provides insight into the microvasculature and endothelial function. Static retinal vessel analysis determines arteriolar and venular vessel diameters and dynamic retinal vessel analysis measures microvascular function by flicker-light induced stimulation, which results in physiological dilation of retinal vessels. We measured 220 healthy individuals and compared them to our preexisting cohort of hemodialysis patients (275 for static and 214 for dynamic analysis). Regarding static vessel diameters, hemodialysis patients and healthy individuals did not significantly differ between vessel diameters. Dynamic retinal vessel analysis showed attenuated dilation of the arteriole of hemodialysis patients with 1.6% vs 2.3% in healthy individuals (p = 0.009). Case-control matching for age (mean 65.4 years) did not relevantly diminish the difference. Hemodialysis patients also exhibited reduced venular dilation after matching for age (3.2% vs 3.8%, p = 0.019). Hemodialysis patients showed microvascular dysfunction compared to healthy individuals when using dynamic retinal vessel analysis. Further studies should focus on dynamic retinal vessel analysis which can add insights into the microvascular function and risk factors in multimorbid patients.
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Affiliation(s)
- Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Matthias Christoph Braunisch
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Timon Kuchler
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Patrizia Glaser
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Felix Schicktanz
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Bernhard Haller
- School of Medicine, Klinikum Rechts der Isar, Institute of AI and Informatics in Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Lukas Streese
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
- Faculty of Health Care, Niederrhein University of Applied Sciences, Krefeld, Germany
| | - Henner Hanssen
- Preventive Sports Medicine and Systems Physiology, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Konstantin Kotliar
- Aachen University of Applied Sciences, Heinrich-Mussmann-Str. 1, 52428, Jülich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum Rechts der Isar, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.
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Makimoto H, Kohro T. Adopting artificial intelligence in cardiovascular medicine: a scoping review. Hypertens Res 2024; 47:685-699. [PMID: 37907600 DOI: 10.1038/s41440-023-01469-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 09/03/2023] [Accepted: 09/26/2023] [Indexed: 11/02/2023]
Abstract
Recent years have witnessed significant transformations in cardiovascular medicine, driven by the rapid evolution of artificial intelligence (AI). This scoping review was conducted to capture the breadth of AI applications within cardiovascular science. Employing a structured approach, we sourced relevant articles from PubMed, with an emphasis on journals encompassing general cardiology and digital medicine. We applied filters to highlight cardiovascular articles published in journals focusing on general internal medicine, cardiology and digital medicine, thereby identifying the prevailing trends in the field. Following a comprehensive full-text screening, a total of 140 studies were identified. Over the preceding 5 years, cardiovascular medicine's interplay with AI has seen an over tenfold augmentation. This expansive growth encompasses multiple cardiovascular subspecialties, including but not limited to, general cardiology, ischemic heart disease, heart failure, and arrhythmia. Deep learning emerged as the predominant methodology. The majority of AI endeavors in this domain have been channeled toward enhancing diagnostic and prognostic capabilities, utilizing resources such as hospital datasets, electrocardiograms, and echocardiography. A significant uptrend was observed in AI's application for omics data analysis. However, a clear gap persists in AI's full-scale integration into the clinical decision-making framework. AI, particularly deep learning, has demonstrated robust applications across cardiovascular subspecialties, indicating its transformative potential in this field. As we continue on this trajectory, ensuring the alignment of technological progress with medical ethics becomes crucial. The abundant digital health data today further accentuates the need for meticulous systematic reviews, tailoring them to each cardiovascular subspecialty.
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Affiliation(s)
- Hisaki Makimoto
- Data Science Center/Cardiovascular Center, Jichi Medical University, Shimotsuke, Japan.
| | - Takahide Kohro
- Data Science Center/Cardiovascular Center, Jichi Medical University, Shimotsuke, Japan
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Danielescu C, Dabija MG, Nedelcu AH, Lupu VV, Lupu A, Ioniuc I, Gîlcă-Blanariu GE, Donica VC, Anton ML, Musat O. Automated Retinal Vessel Analysis Based on Fundus Photographs as a Predictor for Non-Ophthalmic Diseases-Evolution and Perspectives. J Pers Med 2023; 14:45. [PMID: 38248746 PMCID: PMC10817503 DOI: 10.3390/jpm14010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/27/2023] [Accepted: 12/27/2023] [Indexed: 01/23/2024] Open
Abstract
The study of retinal vessels in relation to cardiovascular risk has a long history. The advent of a dedicated tool based on digital imaging, i.e., the retinal vessel analyzer, and also other software such as Integrative Vessel Analysis (IVAN), Singapore I Vessel Assessment (SIVA), and Vascular Assessment and Measurement Platform for Images of the Retina (VAMPIRE), has led to the accumulation of a formidable body of evidence regarding the prognostic value of retinal vessel analysis (RVA) for cardiovascular and cerebrovascular disease (including arterial hypertension in children). There is also the potential to monitor the response of retinal vessels to therapies such as physical activity or bariatric surgery. The dynamic vessel analyzer (DVA) remains a unique way of studying neurovascular coupling, helping to understand the pathogenesis of cerebrovascular and neurodegenerative conditions and also being complementary to techniques that measure macrovascular dysfunction. Beyond cardiovascular disease, retinal vessel analysis has shown associations with and prognostic value for neurological conditions, inflammation, kidney function, and respiratory disease. Artificial intelligence (AI) (represented by algorithms such as QUantitative Analysis of Retinal vessel Topology and siZe (QUARTZ), SIVA-DLS (SIVA-deep learning system), and many others) seems efficient in extracting information from fundus photographs, providing prognoses of various general conditions with unprecedented predictive value. The future challenges will be integrating RVA and other qualitative and quantitative risk factors in a unique, comprehensive prediction tool, certainly powered by AI, while building the much-needed acceptance for such an approach inside the medical community and reducing the "black box" effect, possibly by means of saliency maps.
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Affiliation(s)
- Ciprian Danielescu
- Department of Ophthalmology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Marius Gabriel Dabija
- Department of Surgery II, Discipline of Neurosurgery, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Alin Horatiu Nedelcu
- Department of Morpho-Functional Sciences I, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Vasile Valeriu Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (V.V.L.); (I.I.)
| | - Ancuta Lupu
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (V.V.L.); (I.I.)
| | - Ileana Ioniuc
- Department of Pediatrics, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (V.V.L.); (I.I.)
| | | | - Vlad-Constantin Donica
- Doctoral School, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (V.-C.D.); (M.-L.A.)
| | - Maria-Luciana Anton
- Doctoral School, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (V.-C.D.); (M.-L.A.)
| | - Ovidiu Musat
- Department of Ophthalmology, University of Medicine and Pharmacy “Carol Davila”, 020021 Bucuresti, Romania;
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Lim CC, Chong C, Tan G, Tan CS, Cheung CY, Wong TY, Cheng CY, Sabanayagam C. A deep learning system for retinal vessel calibre improves cardiovascular risk prediction in Asians with chronic kidney disease. Clin Kidney J 2023; 16:2693-2702. [PMID: 38046002 PMCID: PMC10689182 DOI: 10.1093/ckj/sfad227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Indexed: 12/05/2023] Open
Abstract
Backgraund Cardiovascular disease (CVD) and mortality is elevated in chronic kidney disease (CKD). Retinal vessel calibre in retinal photographs is associated with cardiovascular risk and automated measurements may aid CVD risk prediction. Methods Retrospective cohort study of 860 Chinese, Malay and Indian participants aged 40-80 years with CKD [estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2] who attended the baseline visit (2004-2011) of the Singapore Epidemiology of Eye Diseases Study. Retinal vessel calibre measurements were obtained by a deep learning system (DLS). Incident CVD [non-fatal acute myocardial infarction (MI) and stroke, and death due to MI, stroke and other CVD] in those who were free of CVD at baseline was ascertained until 31 December 2019. Risk factors (established, kidney, and retinal features) were examined using Cox proportional hazards regression models. Model performance was assessed for discrimination, fit, and net reclassification improvement (NRI). Results Incident CVD occurred in 289 (33.6%) over mean follow-up of 9.3 (4.3) years. After adjusting for established cardiovascular risk factors, eGFR [adjusted HR 0.98 (95% CI: 0.97-0.99)] and retinal arteriolar narrowing [adjusted HR 1.40 (95% CI: 1.17-1.68)], but not venular dilation, were independent predictors for CVD in CKD. The addition of eGFR and retinal features to established cardiovascular risk factors improved model discrimination with significantly better fit and better risk prediction according to the low (<15%), intermediate (15-29.9%), and high (30% or more) risk categories (NRI 5.8%), and with higher risk thresholds (NRI 12.7%). Conclusions Retinal vessel calibre measurements by DLS were significantly associated with incident CVD independent of established CVD risk factors. Addition of kidney function and retinal vessel calibre parameters may improve CVD risk prediction among Asians with CKD.
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Affiliation(s)
| | - Crystal Chong
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore
| | - Gavin Tan
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore
| | - Chieh Suai Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Carol Y Cheung
- Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong, China
| | - Tien Y Wong
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Ching Yu Cheng
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore
| | - Charumathi Sabanayagam
- Singapore Eye Research Institute, Singapore National Eye Center, Singapore
- Eye-ACP, Duke-NUS Medical School, Singapore
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Heitmar R, Link D, Kotliar K, Schmidl D, Klee S. Editorial: Functional assessments of the ocular circulation. Front Med (Lausanne) 2023; 10:1222022. [PMID: 37359007 PMCID: PMC10285660 DOI: 10.3389/fmed.2023.1222022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 06/28/2023] Open
Affiliation(s)
- Rebekka Heitmar
- Centre for Vision Across the Lifespan, School of Applied Sciences, University of Huddersfield, Huddersfield, United Kingdom
| | - Dietmar Link
- Division Optoelectrophysiological Engineering, Department of Computer Science and Automation, Institute of Biomedical Engineering and Informatics, Technische Universität Ilmenau, Ilmenau, Germany
| | - Konstantin Kotliar
- Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Aachen, Germany
| | - Doreen Schmidl
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Sascha Klee
- Division Optoelectrophysiological Engineering, Department of Computer Science and Automation, Institute of Biomedical Engineering and Informatics, Technische Universität Ilmenau, Ilmenau, Germany
- Division Biostatistics and Data Science, Department General Health Studies, Karl Landsteiner University of Health Sciences, Krems an der Donau, Austria
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Wen J, Liu D, Wu Q, Zhao L, Iao WC, Lin H. Retinal image‐based artificial intelligence in detecting and predicting kidney diseases: Current advances and future perspectives. VIEW 2023. [DOI: 10.1002/viw.20220070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2023] Open
Affiliation(s)
- Jingyi Wen
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
| | - Dong Liu
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
| | - Qianni Wu
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
| | - Lanqin Zhao
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
| | - Wai Cheng Iao
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
| | - Haotian Lin
- State Key Laboratory of OphthalmologyZhongshan Ophthalmic CenterSun Yat‐sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangdong Provincial Clinical Research Center for Ocular Disease GuangzhouChina
- Center for Precision Medicine and Department of Genetics and Biomedical Informatics Zhongshan School of Medicine Sun Yat‐sen University Guangzhou China
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Günthner R, Streese L, Angermann S, Lorenz G, Braunisch MC, Matschkal J, Hausinger R, Stadler D, Haller B, Heemann U, Kotliar K, Hanssen H, Schmaderer C. Mortality prediction of retinal vessel diameters and function in a long-term follow-up of haemodialysis patients. Cardiovasc Res 2022; 118:3239-3249. [PMID: 35576475 DOI: 10.1093/cvr/cvac073] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 04/07/2022] [Accepted: 04/20/2022] [Indexed: 01/25/2023] Open
Abstract
AIM Retinal vessel diameters are candidate biomarkers of mortality prediction in large population-based studies. We aimed to investigate the predictive value of retinal vessel diameters and flicker-induced retinal arteriolar and venular dilation on all-cause mortality in long-term follow-up of haemodialysis patients. METHODS AND RESULTS Retinal vessel diameters as well as maximum arteriolar (aMax) and venular dilation (vMax) were investigated in 275 and 214 haemodialysis patients, respectively. Patients were observed in a long-term follow-up for a median period of 73 months. About 36% (76/214) and 41% (113/275) of patients died. Arteriolar and venular diameters were 175 ± 19 and 208 ± 20 µm, respectively. Median aMax and vMax were 1.6 (0.3-3.3) and 3.2 (2.0-5.1)%. Patients within the lowest tertile of vMax showed lower 5-year survival rates compared with the highest tertile (50.6 vs. 82.1%) and also exhibited a higher incidence of infection-related deaths (21.7 vs. 4.0%). Univariate hazard ratio (HR) per standard deviation increase of vMax for all-cause mortality was 0.69 (0.54-0.88) and was even more pronounced for infection-related mortality [HR 0.53 (0.33-0.83)]. Regarding all-cause mortality, multivariate adjustment for eight non-retinal mortality predictors including interleukin-6 did not attenuate the HR relevantly [0.73 (0.54-0.98)]. Arteriolar and venular diameters did not predict all-cause nor cardiovascular and infection-related mortality. CONCLUSIONS Long-term follow-up of patients on haemodialysis demonstrated the potential of retinal venular dilation capacity for mortality prediction, which was most pronounced for infection-related mortality. In the same cohort, retinal arteriolar and venular diameters showed no predictive value for hard endpoints. Retinal venular dilation but not arteriolar and venular diameters is a valuable diagnostic biomarker for risk prediction in patients with end-stage renal disease and should be considered for monitoring of critically ill patients.
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Affiliation(s)
- Roman Günthner
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Lukas Streese
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Susanne Angermann
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Georg Lorenz
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Matthias C Braunisch
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Julia Matschkal
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - David Stadler
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Bernhard Haller
- Institute for AI and Informatics in Medicine, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Uwe Heemann
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, Aachen University of Applied Sciences, Jülich, Germany
| | - Henner Hanssen
- Division Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Christoph Schmaderer
- Department of Nephrology, School of Medicine, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
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Hanssen H, Streese L, Vilser W. Retinal vessel diameters and function in cardiovascular risk and disease. Prog Retin Eye Res 2022; 91:101095. [PMID: 35760749 DOI: 10.1016/j.preteyeres.2022.101095] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 12/13/2022]
Abstract
In the last two decades evidence has gradually accumulated suggesting that the eye may be a unique window for cardiovascular risk stratification based on the assessment of subclinical damage of retinal microvascular structure and function. This can be facilitated by non-invasive analysis of static retinal vessel diameters and dynamic recording of flicker light-induced and endothelial function-related dilation of both retinal arterioles and venules. Recent new findings have made retinal microvascular biomarkers strong candidates for clinical implementation as reliable risk predictors. Beyond a review of the current evidence and state of research, the article aims to discuss the methodological benefits and pitfalls and to identify research gaps and future directions. Above all, the potential use for screening and treatment monitoring of cardiovascular disease risk are highlighted. The article provides fundamental comprehension of retinal vessel imaging by explaining anatomical and physiological essentials of the retinal microcirculation leading to a detailed description of the methodological approach. This allows for better understanding of the underlying retinal microvascular pathology associated with the prevalence and development of cardiovascular disease. A body of new evidence is presented on the clinical validity and predictive value of retinal vessel diameters and function for incidence cardiovascular disease and outcome. Findings in children indicate the potential for utility in childhood cardiovascular disease prevention, and the efficacy of exercise interventions highlight the treatment sensitivity of retinal microvascular biomarkers. Finally, coming from the availability of normative data, solutions for diagnostic challenges are discussed and conceptual steps towards clinical implementation are put into perspective.
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Affiliation(s)
- Henner Hanssen
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland.
| | - Lukas Streese
- Department of Sport, Exercise and Health, Preventive Sports Medicine and Systems Physiology, Medical Faculty, University of Basel, Switzerland
| | - Walthard Vilser
- Institute of Biomedical Engineering and Informatics, Ilmenau University of Technology, Ilmenau, Germany; Neonatology and Pediatric Intensive Care Unit, Department of Pediatrics, Jena University Hospital, Jena, Germany
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Angermann S, Günthner R, Hanssen H, Lorenz G, Braunisch MC, Steubl D, Matschkal J, Kemmner S, Hausinger R, Block Z, Haller B, Heemann U, Kotliar K, Grimmer T, Schmaderer C. Cognitive impairment and microvascular function in end-stage renal disease. Int J Methods Psychiatr Res 2022; 31:e1909. [PMID: 35290686 PMCID: PMC9159686 DOI: 10.1002/mpr.1909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Hemodialysis patients show an approximately threefold higher prevalence of cognitive impairment compared to the age-matched general population. Impaired microcirculatory function is one of the assumed causes. Dynamic retinal vessel analysis is a quantitative method for measuring neurovascular coupling and microvascular endothelial function. We hypothesize that cognitive impairment is associated with altered microcirculation of retinal vessels. METHODS 152 chronic hemodialysis patients underwent cognitive testing using the Montreal Cognitive Assessment. Retinal microcirculation was assessed by Dynamic Retinal Vessel Analysis, which carries out an examination recording retinal vessels' reaction to a flicker light stimulus under standardized conditions. RESULTS In unadjusted as well as in adjusted linear regression analyses a significant association between the visuospatial executive function domain score of the Montreal Cognitive Assessment and the maximum arteriolar dilation as response of retinal arterioles to the flicker light stimulation was obtained. CONCLUSION This is the first study determining retinal microvascular function as surrogate for cerebral microvascular function and cognition in hemodialysis patients. The relationship between impairment in executive function and reduced arteriolar reaction to flicker light stimulation supports the involvement of cerebral small vessel disease as contributing factor for the development of cognitive impairment in this patient population and might be a target for noninvasive disease monitoring and therapeutic intervention.
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Affiliation(s)
- Susanne Angermann
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Roman Günthner
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Henner Hanssen
- Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
| | - Georg Lorenz
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Matthias C Braunisch
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Dominik Steubl
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Julia Matschkal
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Stephan Kemmner
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany.,Transplant Center, University Hospital Munich, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Renate Hausinger
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Zenonas Block
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Bernhard Haller
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
| | - Konstantin Kotliar
- Department of Medical Engineering and Technomathematics, FH Aachen University of Applied Sciences, Campus Jülich, Jülich, Germany
| | - Timo Grimmer
- Department of Psychiatry and Psychotherapy, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munchen, Germany
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