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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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Fukutsu K, Saito M, Noda K, Murata M, Kase S, Shiba R, Isogai N, Asano Y, Hanawa N, Dohke M, Kase M, Ishida S. Relationship between Brachial-Ankle Pulse Wave Velocity and Fundus Arteriolar Area Calculated Using a Deep-Learning Algorithm. Curr Eye Res 2022; 47:1534-1537. [PMID: 36000916 DOI: 10.1080/02713683.2022.2117384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE Retinal vessels reflect alterations related to hypertension and arteriosclerosis in the physical status. Previously, we had reported a deep-learning algorithm for automatically detecting retinal vessels and measuring the total retinal vascular area in fundus photographs (VAFP). Herein, we investigated the relationship between VAFP and brachial-ankle pulse wave velocity (baPWV), which is the gold standard for arterial stiffness assessment in clinical practice. METHODS Retinal photographs (n = 696) obtained from 372 individuals who visited the Keijinkai Maruyama Clinic for regular health checkups were used to analyze VAFP. Additionally, the baPWV was measured for each patient. Automatic retinal-vessel segmentation was performed using our deep-learning algorithm, and the total arteriolar area (AA) and total venular area (VA) were measured. Correlations between baPWV and several parameters, including AA and VA, were assessed. RESULTS The baPWV was negatively correlated with AA (R = -0.40, n = 696, P < 2.2e-16) and VA (R = -0.36, n = 696, P < 2.2e-16). Independent variables (AA, sex, age, and systolic blood pressure) selected using the stepwise method showed a significant correlation with baPWV. The estimated baPWV, calculated using a regression equation with variables including AA, showed a better correlation with the measured baPWV (R = 0.70, n = 696, P < 2.2e-16) than the estimated value without AA (R = 0.68, n = 696, P < 2.2e-16). CONCLUSIONS AA and VA were significantly correlated with baPWV. Moreover, baPWV estimated using AA correlated well with the actual baPWV. VAFP may serve as an alternative biomarker for evaluating systemic arterial stiffness.
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Affiliation(s)
- Kanae Fukutsu
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Michiyuki Saito
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kousuke Noda
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Ocular Circulation and Metabolism, Hokkaido University, Sapporo, Japan
| | - Miyuki Murata
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Ocular Circulation and Metabolism, Hokkaido University, Sapporo, Japan
| | - Satoru Kase
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | | | | | | | | | | | | | - Susumu Ishida
- Department of Ophthalmology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.,Department of Ocular Circulation and Metabolism, Hokkaido University, Sapporo, Japan
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3
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Zhang W, Li J, Zhao L, Zhang J, She H, Meng Y, Peng Y, Shang K, Zhang Y, Gu X, Chen X, Zhang Y, Yang Y, Sun P, Qin X, Wang B, Xu X, Hou F, Tang G, Liao R, Lin T, Jiang C, Huo Y, Yang L. Positive relationship of hypertensive retinopathy with carotid intima--media thickness in hypertensive patients. J Hypertens 2020; 38:2028-2035. [PMID: 32890279 DOI: 10.1097/hjh.0000000000002509] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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 (β, 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; β, 13.70, 95% CI: 5.65--21.75; versus ≥60 years; β, 1.03, 95% CI: -5.58 to 7.63; P interaction = 0.006); or with lower total homocysteine levels [<12.1 μmol/l (median); β, 12.70, 95% CI: 5.98--19.42; versus ≥12.1 μmol/l; β, 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.
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Affiliation(s)
- Wenbo Zhang
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Jun Li
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Liang Zhao
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Jing Zhang
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Haicheng She
- Beijing Ophthalmology and Visual Science Key Laboratory, Beijing Tongren Eye Center, Beijing Tongren Hospital, Capital Medical University, Beijing
| | - Ying Meng
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Yuan Peng
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Kun Shang
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Yadi Zhang
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Xiaopeng Gu
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Xuling Chen
- Department of Ophthalmology, Peking University First Hospital, Beijing
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing
| | - Ying Yang
- Department of Cardiology, Peking University First Hospital, Beijing
| | - Pengfei Sun
- Department of Cardiology, Peking University First Hospital, Beijing
| | - Xianhui Qin
- National Clinical Research Study Center for Kidney Disease; State Key Laboratory for Organ Failure Research; Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Binyan Wang
- Institute of Biomedicine, Anhui Medical University, Hefei
| | - Xiping Xu
- National Clinical Research Study Center for Kidney Disease; State Key Laboratory for Organ Failure Research; Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing
| | - Fanfan Hou
- National Clinical Research Study Center for Kidney Disease; State Key Laboratory for Organ Failure Research; Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Genfu Tang
- School of Health Administration, Anhui University
| | - Rongfeng Liao
- Department of Ophthalmology, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tengfei Lin
- Beijing Advanced Innovation Center for Food Nutrition and Human Health, College of Food Science and Nutritional Engineering, China Agricultural University, Beijing
| | - Chongfei Jiang
- National Clinical Research Study Center for Kidney Disease; State Key Laboratory for Organ Failure Research; Renal Division, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing
| | - Liu Yang
- Department of Ophthalmology, Peking University First Hospital, Beijing
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Liu M, Lycett K, Wong TY, Grobler A, Juonala M, He M, Dwyer T, Burgner D, Wake M. Associations of retinal microvascular caliber with large arterial function and structure: A population-based study of 11 to 12 year-olds and midlife adults. Microcirculation 2020; 27:e12642. [PMID: 32490591 DOI: 10.1111/micc.12642] [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: 07/11/2019] [Revised: 02/27/2020] [Accepted: 05/24/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We examined associations between retinal microvascular and large arterial phenotypes to explore relationships between the micro- and macro-vasculature in childhood and midlife. METHODS Participants were 1288 children (11-12 years, 50.9% female) and 1264 adults (mean age 44 years, 87.6% female) in a cross-sectional population-based study. Exposures were retinal arteriolar and venular caliber quantified from retinal images. Outcomes included arterial function (pulse wave velocity; carotid arterial elasticity) and structure (carotid intima-media thickness). Multivariable regression models were performed adjusting for age, sex, and family socioeconomic position. RESULTS In children, one standard deviation wider arteriolar caliber was associated with slower pulse wave velocity (-0.15 SD, 95% CI -0.21, -0.09) and higher elasticity (0.13 SD, 95% CI 0.06, 0.20); per SD wider venular caliber was associated with faster pulse wave velocity (0.09 SD, 95% CI 0.03, 0.15) and lower elasticity (-0.07 SD, 95% CI -0.13, -0.01). The size of adult associations was approximately double. Wider arteriolar caliber was associated with smaller carotid intima-media thickness (-0.09 SD, 95% CI -0.16, -0.03) in adults but not children. Venular caliber and carotid intima-media thickness showed little evidence of association. CONCLUSIONS Narrower retinal arterioles and wider venules are associated with large arterial function as early as mid-childhood. Associations strengthen by midlife and also extend to arterial structure, although effect sizes remain small.
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Affiliation(s)
- Mengjiao Liu
- The University of Melbourne, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Kate Lycett
- The University of Melbourne, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Centre for Social & Early Emotional Development, Deakin University, Melbourne, Vic., Australia
| | - Tien Yin Wong
- The University of Melbourne, Melbourne, Vic., Australia.,Department of Ophthalmic Epidemiology, Centre for Eye Research Australia, The University of Melbourne, Melbourne, Vic., Australia.,Singapore Eye Research Institute, Singapore National Eye Center, Singapore, Singapore
| | - Anneke Grobler
- The University of Melbourne, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia
| | - Markus Juonala
- Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Department of Internal Medicine, University of Turku, Turku, Finland.,Division of Medicine, Turku University Hospital, Turku, Finland
| | - Mingguang He
- The University of Melbourne, Melbourne, Vic., Australia.,Department of Ophthalmic Epidemiology, Centre for Eye Research Australia, The University of Melbourne, Melbourne, Vic., Australia.,State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-Sen University, Guangzhou, China
| | - Terry Dwyer
- Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - David Burgner
- The University of Melbourne, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Department of Paediatrics, Monash University, Melbourne, Vic., Australia.,Infectious Diseases, Royal Children's Hospital, Melbourne, Vic., Australia
| | - Melissa Wake
- The University of Melbourne, Melbourne, Vic., Australia.,Murdoch Children's Research Institute, Melbourne, Vic., Australia.,Department of Paediatrics & The Liggins Institute, The University of Auckland, Auckland, New Zealand
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Liu M, Wake M, Wong TY, He M, Xiao Y, Burgner DP, Lycett K. Associations of retinal microvascular caliber with intermediate phenotypes of large arterial function and structure: A systematic review and meta‐analysis. Microcirculation 2019; 26:e12557. [DOI: 10.1111/micc.12557] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/25/2019] [Accepted: 05/09/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Mengjiao Liu
- Murdoch Children's Research InstituteRoyal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
| | - Melissa Wake
- Murdoch Children's Research InstituteRoyal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Department of Paediatrics The Liggins InstituteThe University of Auckland Auckland New Zealand
| | - Tien Yin Wong
- Department of Ophthalmic Epidemiology Centre for Eye Research Australia The University of Melbourne Melbourne Victoria Australia
- Singapore Eye Research InstituteSingapore National Eye Center Singapore Singapore
- Duke‐NUS Medical SchoolNational University of Singapore Singapore Singapore
| | - Mingguang He
- Department of Ophthalmic Epidemiology Centre for Eye Research Australia The University of Melbourne Melbourne Victoria Australia
- State Key Laboratory of Ophthalmology Zhongshan Ophthalmic CenterSun Yat‐Sen University Guangzhou China
| | - Yinzong Xiao
- Department of Ophthalmic Epidemiology Centre for Eye Research Australia The University of Melbourne Melbourne Victoria Australia
| | - David P. Burgner
- Murdoch Children's Research InstituteRoyal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Department of Paediatrics Monash University Melbourne Victoria Australia
| | - Kate Lycett
- Murdoch Children's Research InstituteRoyal Children's Hospital Melbourne Victoria Australia
- Department of Paediatrics The University of Melbourne Melbourne Victoria Australia
- Centre for Social & Early Emotional Development Deakin University Melbourne Victoria Australia
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Pulsatile interaction between the macro-vasculature and micro-vasculature: proof-of-concept among patients with type 2 diabetes. Eur J Appl Physiol 2018; 118:2455-2463. [DOI: 10.1007/s00421-018-3972-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
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7
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Association of retinal vessel calibers and longitudinal changes in arterial stiffness. J Hypertens 2018; 36:587-593. [DOI: 10.1097/hjh.0000000000001602] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rizzoni D, Agabiti Rosei C, De Ciuceis C, Semeraro F, Rizzoni M, Docchio F. New Methods to Study the Microcirculation. Am J Hypertens 2018; 31:265-273. [PMID: 29228086 DOI: 10.1093/ajh/hpx211] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Essential hypertension is associated with structural alterations in the microvessels; in particular, an increase in the media thickness to internal lumen ratio of small resistance arteries (MLR) and a reduction in capillary density have been observed. The evaluation of the morphological characteristics of small resistance arteries in humans is challenging. The gold-standard method is generally considered to be the measurement by wire or pressure micromyography of MLR of subcutaneous small vessels obtained by local biopsies. However, noninvasive techniques for the evaluation of retinal arterioles were recently proposed; in particular, 2 approaches, scanning laser Doppler flowmetry (SLDF) and adaptive optics (AO), seem to provide useful information. Both of them provide an estimation of the wall to lumen ratio (WLR) of retinal arterioles. Moreover, a noninvasive measurement of basal and total capillary density may be obtained by videomicroscopy/capillaroscopy. It has been recently demonstrated that AO has a substantial advantage over SLDF in terms of evaluation of microvascular morphology, since WLR measured with AO is more closely correlated with the M/L of subcutaneous small arteries. The possibility to noninvasively assess in a reliable way, microvascular morphology in a clinical setting may represent a major advancement, since micromyography has substantial limitations in its application due to the local invasiveness of the procedure.
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Affiliation(s)
- Damiano Rizzoni
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Istituto Clinico Città di Brescia, Division of Medicine, Brescia, Italy
| | - Claudia Agabiti Rosei
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Carolina De Ciuceis
- Clinica Medica, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Francesco Semeraro
- Eye Clinic, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Rizzoni
- Department of Information Engineering, University of Brescia, Brescia, Italy
| | - Franco Docchio
- Department of Mechanical and Industrial Engineering, University of Brescia, Brescia, Italy
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