Does treatment for hypertension protect against retinopathy? Skaraborgs Diabetesregister (SDR) ten years follow up Grete Garberg, MD Skaraborg Hospital

Background I Diabetic retinopathy main reason for visual impairment in working ages, patients fear ”blindness” Important to prevent Type 2 diabetes retinopathy not unusual at diagnosis Screening is effective to detect retinopathy makes treatment possible before symptoms evolve

Background II Screening in Skaraborg from late 1980 patients in ages < 70 years Skaraborgs Diabetes Register (SDR) 1991-2004 clinical data and data on morbidity and mortality Patients type 2 (+0=undefined)diagnosed 1996-1998 the basis of this study

SDR cohort 1996-1998 1258 (305 dead ) 381 ≥70 yrs at baseline (187 877 < 70 (118 6 undefined 2 type 1 403 8 104 765 Population 2007-2010 Cohorterna (ABC) har du inte beskrivit senare. Skriv inte typ 0 det finns väl ingen definition av den? SDR=Skaraborgs diabetesregister 4

Methods Data from retinal screening close to diagnosis and after 5 and 10 years From screening records retinopathy, maculopathy, laser treatment, visual acuity and other reasons for visual impairment From Skaraborgs Diabetes Register HbA1c, body mass index (BMI), blood pressure (BP) and antihypertensive treatment

Diabetic retinopathy in all patients (type 1+2+0) Results I a Diabetic retinopathy in all patients (type 1+2+0) Number of patients Examination 1996-1998 Examination 2000-2002 2003- 2009§ Examined 362 630 649 Any retinopathy 26 88 168 Maculopathy 5 19 38 Proliferative retinopathy 12 Laser treatment A maculopathy B scatter 3 10 23 22 10 (1 BRVO) Visual acuity >0.5 <0.3 331 324 618 607 637 616 9 Mortality 22* 57** 117*** *Before 01/01/99, ** Before 01/01/03, *** Before 10/08/09, § last examination

Diabetic retinopathy in patients type 0+2 <70 years at baseline Results I Diabetic retinopathy in patients type 0+2 <70 years at baseline Number of patients Examination 1996-1998 Examination 2000-2002 2003- 2009§ Examined 288 540 559 Any retinopathy 21 76 144 (25,6%) Maculopathy 3 15 32(5,7%) Proliferative retinopathy 2 7 (1.4%) Laser treatment A maculopathy B scatter 7 1 19 (3.4%) 18 6 (1 BRVO) Visual acuity >0.5 <0.3 264 259 541 514 5 548 527 9 Mortality 20* 53** 114*** *Before 01/01/99, ** Before 01/01/03, *** Before 10/08/09, § last examination

Results summary I Frequency of screening 83% (639/773) of patients <70 years at diagnosis screened some time during follow-up HbA1C at diagnosis Mean value 6,66% Visual acuity 96% (527/548) >0.5 at the last recorded examination Fanns det inte data om visual acuity på alla utan bara på 639?? 8

HbA1C at diagnosis

Results IIa HbA1C in 1996-1998 HbA1c < 7.0 % ≥7.0 % p < 8.0 % Retinopathy 88 (22.4%) 71 (38.6%) < 0.001 Maculopathy 15 (4.0%) 18 (9.8%) 0.006 < 8.0 % ≥8.0 % 114 (24.4%) 45 (41.7%) 20 (4.4%) 13 (11.9%) 0.003

Results IIb HbA1C and time to retinopathy

Results IIc HbA1C and time to maculopathy

Results IId BMI in 96-98 and retinopathy

Results IIe BMI in 96-98 and maculopathy

Results IIIa Blood pressure and hypertension Systolic blood pressure <130 mmHg Associated with less retinopathy Systolic blood pressure >130 mmHg Further increase in systolic blood pressure not associated with more retinopathy. Blood pressure at baseline Not associated with retinopathy or maculopathy Hypertension treatment at baseline Punkt 1 och 2 stämmer inte, hur ligger det till? 15

Results IIIb Antihypertensive treatment and retinopathy Försök att översätta texten i figuren till engelska. Fråga Johanna man måste kanske göra det ifrån SPSS programmet. 16

Results IIIc Antihypertensive treatment and maculoopathy Samma här gärna engelska i figuren 17

Conclusions I Relatively few patients with visual impairment Retinopathy increases rapidly after 10 years duration Older diabetic’s visual impairment is often due to complicating eye disease. Kanske bara säga detta du visar kanske inte data och det blir lite för mycket information om du skall koncentrera dig på hypertonin. 18

Conclusions II HbA1C level at diagnosis seems to predict risk for retinopathy and maculopathy BMI at diagnosis does not affect development of retinopathy

Conclusions III Antihypertensive treatment regardless of BP level associated with lower frequency of retinopathy lower frequency of maculopathy

Thank you for your attention! Questions or comments?

Thanks for contribution from R&D Centre, Skaraborg Hospital, financing Bo Berger, PhD Kristina A Boström, Supervisor; PhD, R&D Centre Skaraborg Primary Care Monica Lövestam Adrian, Suprervisor; PhD, Eye Clinic, Lund University Hospital Salmir Nasic, Statistician, Skaraborg Hospital Ann Segerblom, Research Assistent, R&D Centre Skaraborg Primary Care