Can Ophthalmoscope Predict Silent Coronary Artery Disease in Patients with Type 2 Diabetes Mellitus?


Background & Aim: Diabetic retinopathy (DR) and Coronary Artery Disease (CAD) share similar pathophysiological background of vascular damage. So we aimed to study the relationship between DR and silent CAD in patients with type 2 diabetes mellitus (T2DM). Subject & Methods: A cross sectional study was performed on 40 patients with T2DM from diabetic outpatient clinic in Ain Shams University Hospitals, Cairo, Egypt from June 2012 to December 2012. All patients were subjected to data collection, laboratory analysis and imaging studies. Patients with known CAD, abnormal resting or stress ECG, abnormal ejection fraction or segmental wall motion abnormalities, smoking history, hypertension, or abnormal lipid profile were excluded. Results: Mean age is 62.35 ± 1.38 years, 75% (n = 30) were females, 75% (n = 30) had DR, and 77.50% (n = 31) had positive Tc99 scan. There is a significant positive association between Tc99 scan and DR (p value = 0.029) as 86.7% of patients with DR had positive Tc99 scan. Resting and stress perfusion TC99 scan were significantly worse (91.77% vs 100%; 86.48% vs 96.27%, p value = 0.008, 0.005 respectively) and microalbuminuria were significantly higher (207 ± 29.65 vs 36 ± 10.66 mg/dl, p value =< 0.001) in patients with DR. By binary logistic regression, DR was an independent predictor for CAD (OR was 16.377, 95% CI was 1.017 - 263.586, p value = 0.049) after adjustment of SBP and albuminuria. Conclusion: DR is an independent predictor of asymptomatic CAD even with normal stress ECG and echocardiography. Routine screening for CAD using Tc99 scan is recommended in patients with DR even if asymptomatic. More multi-centric prospective studies are needed to elucidate the effect of the degree of DR on CAD risk.

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Soliman, N. and Abd-El Gawad, W. (2014) Can Ophthalmoscope Predict Silent Coronary Artery Disease in Patients with Type 2 Diabetes Mellitus?. Advances in Aging Research, 3, 360-367. doi: 10.4236/aar.2014.35046.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Keenan, H.A., Costacou, T., Sun, J.K., Doria, A., Cavellerano, J., Coney, J., Orchard, T.J., Aiello, L.P. and King, G.I. (2007) Clinical Factors Associated With Resistance to Microvascular Complications in Diabetic Patients of Extreme Disease Duration. The 50-Year Medalist Study. Diabetes Care, 30, 1995-1997.
[2] Hogan, P., Dall, T. and Nikolov, P. (2003) Economic Costs of Diabetes in the Us in 2002. Diabetes Care, 26, 917-932.
[3] Cheung, N., Liewb, G. and Wonga, T.Y. (2010) Current Approaches to Retinopathy as a Predictor of Cardiovascular Risk. In: Hammes, H.-P. and Porta, M., Eds., Experimental Approaches to Diabetic Retinopathy, Vol. 20, Front Diabetes, Karger, Basel, 203-219.
[4] Cheung, N. and Wong, T.Y. (2007) Diabetic Retinopathy and Systemic Vascular Complications. Progress in Retinal and Eye Research, 27, 161-176.
[5] Cheung, N., Mitchell, P. and Wong, T.Y. (2010) Diabetic Retinopathy. Lancet, 376, 124-136.
[6] Cheung, N., Wang, J.J., Rogers, S.L., Brancati, F., Klein, R., Sharrett, A.R. and Wong, T.Y., ARIC (Atherosclerosis Risk in Communities) Study Investigators (2008) Diabetic Retinopathy and Risk of Heart Failure. Journal of the American College of Cardiology, 51, 1573-1578.
[7] American Academy of Ophthalmology (2003) Preferred Practice Pattern. Diabetic Retinopathy 2003. Calif, San Francisco.
[8] Scholte, A., Schuijf, J., Kharagjitsingh, A., Dibbets-Schneider, P., Stokkel, M., Van Der Wall, E., et al. (2009) Prevalence and Predictors of an Abnormal L Stress Myocardial Perfusion Study in Asymptomatic Patients with Type 2 Diabetes Mellitus. European Journal of Nuclear Medicine and Molecular Imaging, 36, 567-575.
[9] Underwood, S.R., Anagnostopoulos, C., Cerqueira, M., Ell, P.J., Flint, E.J., Harbinson, M., et al. (2004) Myocardial Perfusion Scintigraphy: The Evidence. A Consensus Conference Organized by the British Cardiac Society, the British Nuclear Cardiology Society and the British Nuclear Medicine Society, Endorsed by the Royal College of Physicians of London and the Royal College of Radiologists. European Journal of Nuclear Medicine and Molecular Imaging, 31, 261-291.
[10] Roelker, E. (2008) Screening for Coronary Artery Disease in Patients with Diabetes. Diabetes Spectrum, 21, 166-171.
[11] Fricke, E., Fricke, H., Weise, R., Kammeier, A., Hagedorn, R., Lotz, N., Lindner, O., Tschoepe, D. and Burchert, W. (2005) Attenuation Correction of Myocardial SPECT Perfusion Images with Low-Dose CT: Evaluation of the Method by Comparison with Perfusion Pet. Journal of Nuclear Medicine, 46, 736-744.
[12] Fuller, J.H., Stevens, L.K. and Wang, S.L., the WHO Multinational Study Group (2001) Risk Factors for Cardiovascular Mortality and Morbidity: The WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia, 44, S54-S64.
[13] Kawasaki, R., Tanaka, S., Sone, H., Yokote, K., Ishibashi, S., Katayama, S., et al. (2013) Risk of Cardiovascular Diseases Is Increased Even with Mild Diabetic Retinopathy. The Japan Diabetes Complications Study. Ophthalmology, 120, 574-582.
[14] Kramer, C.K., Rodrigues, T.C., Canani, L.H., Gross, J.L. and Azevedo, M.J. (2011) Diabetic Retinopathy Predicts All-Cause Mortality and Cardiovascular Events in both Type 1 and 2 Diabetes. Meta-Analysis of Observational Studies. Diabetes Care, 34, 1238-1244.
[15] Gimelli, A., Rossi, G., Landi, P., Marzullo, P., Iervasi, G., L’Abbate, A. and Rovai, D. (2009) Stress/Rest Myocardial Perfusion Abnormalities by Gated SPECT: Still the Best Predictor of Cardiac Events in Stable Ischemic Heart Disease. Journal of Nuclear Medicine, 50, 546-553.
[16] Albers, A.R., Krichavsky, M.Z. and Balady, G.J. (2006) Stress Testing in Patients with Diabetes Mellitus: Diagnostic and Prognostic Value. Circulation, 113, 583-592.
[17] Ioannidis, G.L., Peppa, M., Rontogianni, P., Callifronas, M., Papadimitriou, C., Chrysanthopoulou, G., Anthopoulos, L., Kesse, M. and Thalassinos, N. (2004) The Concurrence of Microalbuminuria and Retinopathy with Cardiovascular Risk Factors; Reliable Predictors of Asymptomatic Coronary Artery Disease in Type 2 Diabetes. Hormones (Athens), 3, 198-203.
[18] Hernández, C.L., Candell-Riera, J., Ciudin, A., Francisco, G., Aguadé-Bruix, S. and Simó, R. (2011) Prevalence and Risk Factors Accounting for True Silent Myocardial Ischemia: A Pilot Case-Control Study Comparing Type 2 Diabetic with Non-Diabetic Control Subjects. Cardiovascular Diabetology, 10, 9.
[19] Factor, S.M., Okun, E.M. and Minase, T. (1980) Capillary Microaneurysms in the Human Diabetic Heart. New England Journal of Medicine, 302, 384-388.
[20] Giugliano, D., Acampora, R., De Rosa, N., Quatraro, A., De Angelis, L., Ceriello, A. and D’Onofrio, F. (1993) Coronary Artery Disease in Type-2 Diabetes Mellitus: A Scintigraphic Study. Diabete & Metabolisme, 19, 463-466.
[21] Celik, T., Berdan, M.E., Iyisoy, A., Kursaklioglu, H., Turhan, H., Kilic, S., Gulec, M., Ozturk, S. and Isik, E. (2005) Impaired Coronary Collateral Vessel Development in Patients with Proliferative Diabetic Retinopathy. Clinical Cardiology, 28, 384-388.
[22] Norgaz, T., Hobikoglu, G., Aksu, H., Guveli, A., Aksoy, S., Ozer, O., Bolca, O. and Narin, A. (2005) Retinopathy Is Related to the Angiographically Detected Severity and Extent of Coronary Artery Disease in Patients with Type 2 Diabetes Mellitus. International Heart Journal, 46, 639-646.
[23] Chavers, B.M., Mauer, S.M., Ramsay, R.C. and Steffes, M.W. (1994) Relationship between Retinal and Glomerular Lesions in IDDM Patients. Diabetes, 43, 441-446.
[24] Nag, S., Robertson, D.M. and Dinsdale, H.B. (1980) Morphological Changes in Spontaneously Hypertensive Rats. Acta Neuropathologica, 52, 27-34.
[25] Cruickshanks, K.J., Ritter, L.L., Klein, R. and Moss, S.E. (1993) The Association of Microalbuminuria with Diabetic Retinopathy. The Wisconsin Epidemiologic Study of Diabetic Retinopathy. Ophthalmology, 100, 862-867.
[26] Edwards, M.S., Wilson, D.B., Craven, T.E., Stafford, J., Fried, L.F., Wong, T.Y., Klein, R., Burke, G.L. and Hansen, K.J. (2005) Associations between Retinal Microvascular Abnormalities and Declining Renal Function in the Elderly Population: The Cardiovascular Health Study. American Journal of Kidney Diseases, 46, 214-224.
[27] Klein, R., Klein, B.E., Moss, S.E. and Cruickshanks, K.J. (1995) Ten-Year Incidence of Gross Proteinuria in People with Diabetes. Diabetes, 44, 916-923.
[28] Frank, R.N. (2004) Diabetic Retinopathy. New England Journal of Medicine, 350, 48-58.

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