Author: Ana Filipa Moleiro (Portugal)
Co-authors: Ana Filipa Moleiro, Vânia Sousa, Danilo Jesus, Francisco Vasques-Nóvoa, Amândio Rocha-Sousa, João Barbosa-Breda
Purpose
Heart Failure (HF) with preserved Ejection Fraction (HFpEF) constitutes a complex and poorly understood disease which is characterized by recurring exacerbations, often requiring frequent venous blood sample collection and serial echocardiography to guide therapy optimization. The development of easy-to-perform non-invasive biomarkers for HFpEF risk stratification and prognosis could translate in significant gains in quality of life and less direct and indirect health-related costs. Optical coherence tomography angiography (OCTA) is a fast, reproducible and non-invasive ocular exam that can produce a highly detailed vascular analysis at the capillary level. Since previous evidence has demonstrated significant OCTA changes in the retinal and choroidal microcirculations of patients with systemic cardiovascular diseases, we hypothesize that HFpEF may also lead to alterations in ocular micro-vascularity. The purpose of this work was to characterize the ocular microvasculature of HFpEF patients recurring to OCTA.
Setting/Venue
This work took place in the Department of Ophthalmology of São João Hospital Center in Porto, Portugal, in collaboration with the Cardiovascular Research Unit (UniC) of the Faculty of Medicine of University of Porto, Portugal.
Methods
Fifty-seven HFpEF patients and twelve comorbity-matched controls were recruited from the outpatient clinic. OCTA examination (Cirrus 5000, AngioPlex®, Carl Zeiss) was carried out by an experienced technician. Vessel densities (VD) were calculated in the superficial and deep retinal plexus as well as in the choriocapillaris and choroid layers of the disc centered images. Foveal avascular zone (FAZ) area and perimeter were also calculated on macula centered images. Only high-quality images (score higher than 7/10 and no major artefacts) were considered. Also, eyes were excluded if ocular pathologies besides minor refractive error/incipient cataract were present. Statistics were performed using SPSS version 27. Normality of the data were assessed. Independent sample T-test, Mann-Whitney or Kruskal-Wallis tests were applied to compare groups, when appropriate. P values lower than 0.05 were considered to be statistically significant.
Results
After excluding patients for concomitant ocular pathology or low-quality images, 56 eyes from 33 patients and 20 eyes from 10 controls were included. The sample included 17 women and 26 men. Among HFpEF patients, twelve were classified as New York Heart Association (NYHA) class 1, nineteen as class 2 and only two patients as class 3. No significant differences in peripapillary superficial and deep retinal capillary plexus were found between controls and patients (p=0.464 and p=0.869, respectively) neither between different NYHA classes (p=0.960 and p=0.772, respectively). However, nasal choriocapillaris VD was significantly lower in HFpEF patients than controls (p=0.008). Furthermore, choroid VD is not different between controls and HFpEF patients but is significantly different when comparing the different classes of NYHA (p=0.026). Results show a significant increase of choroidal VD from controls to NYHA class 1 followed by a significant decrease in more severe classes. Regarding macula-centered scans, FAZ area and perimeter were significantly higher in HFpEF patients than in controls (p=0.013 and p=0.011 respectively). This difference holds when comparing the different NYHA classes of patients (p=0.031 and p=0.028, respectively), suggesting an enlargement of this zone with the severity of the disease.
Conlusions
Our results demonstrate an enlargement of FAZ area and perimeter in HFpEF patients in comparison to comorbidity-matched controls. These FAZ changes seem to also be correlated with NYHA class. Furthermore, we also show a significant decrease of VD in the nasal peripapillary area of the choricocappilaris and whole choroid layers. Significant differences were not identified in the peripapillary retinal plexus. It is known that HF is characterized by an autonomic dysregulation. The presence of changes in the choroidal circulation but not in the retinal plexus may reflect dysregulation of the autonomic system with preservation of the retinal autoregulation. However, we need to take into account that almost all included patients were classified as NYHA classes 1 or 2, which are the least severe classes. It is possible that more severe cases may already show retinal autoregulation impairment. To the best of our knowledge, this is the first work evaluating OCTA features on HFpEF patients. Although more robust evidence is needed to better understand these changes, we can conclude that OCTA could be a useful tool to assess vessel dysregulation in HFpEF.
Financial Disclosure
None
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