Expanded Field OCTA Biomarkers Associated with Future Cardiovascular Disease and Mortality in Patients with Diabetic Retinopathy

Purpose: To explore associations among expanded field swept-source optical coherence tomography angiography (SS-OCTA) metrics and the development of myocardial infarction (MI), congestive heart failure (CHF), and all-cause mortality in diabetic patients with and without diabetic retinopathy (DR). Methods: Baseline SS-OCTA images (6×6mm, Montage 15×15mm ) were assessed for quantitative and qualitative metrics to identify parameters associated with MI, CHF, and all-cause mortality. Results: 178 eyes from 119 adults with diabetes without DR or with NPDR or PDR were included (median 44 months, range 3-57). 11 participants (9.2%) had a cardiovascular event (6 MI, 5 CHF), and 7 (5.9%) died. Neovascularization vessel density (HR=44.0, 95% CI: 1.0-1,861.2, P=0.048) and vitreous hemorrhage (HR=39.7, 95% CI: 4.0-392.8, P=0.002) were associated with CHF. Vitreous hemorrhage (HR=13.5, 95% CI: 3.0-61.2, P=0.001) and prior treatment with anti-VEGF injections and panretinal photocoagulation (HR=11.4, 95% CI: 2.0-66.3, P=0.007) were associated with cardiovascular disease (CHF or MI). Increased skeletonized vessel density of the deep capillary plexus (DCP) (HR=1.2, 95% CI: 1.0-1.5, P=0.026) was associated with mortality. Conclusion: Neovascularization vessel density and skeletonized vessel density of the DCP on SS-OCTA are associated with cardiovascular disease and mortality in patients with DR. These exploratory findings suggest SS-OCTA may be a useful non-invasive tool to identify diabetic patients at increased risk of cardiovascular disease and death.