Letter to the Editor Letters to the Editor will be published, if suitable, as space permits. They should not exceed 500 words (typed double-spaced) plus 5 references in length and may be subject to editing or abridgment.
Assessment of Retinal Vasculature in Pregnancy: Unveiling the Complex Pathogenesis of Gestational Vascular Complications To the Editor: Lupton et al1 get our applause for their innovative study on retinal microvascular alterations and subsequent development of preeclampsia. Changes in retinal calibers are not only overt in the early stages of essential hypertension as shown previously by our group2 but are now for the first time implicated in the multifaceted hypertensive disorder of preeclampsia. However, data on blood pressure (BP) levels and unadjusted for BP retinal calibers are not provided by the authors. Although normotensive until 20 weeks of gestation, women who subsequently develop preeclampsia may lack the BP drop normally observed during first weeks of pregnancy and exhibit prehypertensive BP levels. Indeed, normal but higher BP levels during the first trimester are observed in women who later develop hypertensive pregnancy disorders, compared with uncomplicated pregnancy.3 Therefore, it would be rational to hypothesize that in the present study, BP differences might account for the differences in adjusted for BP retinal calibers. Likewise, could BP control after the establishment of preeclampsia after the 20th week account for the nonsignificant changes in cCRAE (corrected central retinal arterioral equivalent) at 29 weeks and cCRVE (corrected central retinal venular equivalent) at 29 and 38 weeks in the preeclampsia group? Another concern regards venular constriction in the preclinical stage of preeclampsia, represented by the adjusted for BP cCRVE. Potentially responsible mechanisms proposed by the authors, with inflammation being a common denominator, typically induce venular dilatation. Again, increased BP might account for this effect but data are lacking. Either way, the effect of inflammatory status preceding preeclampsia on retinal vascular calibers warrants thorough investigation. In addition, whether altered microcirculation mirrored in retinal vasculature precedes or succeeds the pathophysiological series leading to preeclampsia cannot be concluded because of lack of pregestational and postpartum measurements. Women in the preeclampsia group exhibited a worse cardiovascular risk profile, suggested by their increased age, body mass index, smoking habits, and previous history of hypertensive pregnancy disorders, which has been associated with increased risk of subsequent hypertension and cardiovascular disease.4 Both retinal microvascular alterations and hypertensive pregnancy disorders share mutual cardiovascular risk factors and are more frequently observed in individuals with an aggravated cardiovascular risk profile. Therefore, retinal microvascular alterations might have pre-existed in women who later developed preeclampsia. It could be said that hypertension and preeclampsia represent 2 sides of the same coin, which is an aggravated cardiovascular profile, repeatedly found to correlate or even be predicted by retinal microvascular alterations. Finally, we recently showed that a worse cardiovascular profile, estimated with Framingham risk score, may be predicted by the presence of both retinal vessel alterations and microalbuminuria.5
It would be interesting to know whether retinal arterioral diameters correlated with proteinuria, a key sign of preeclampsia, in the population of the present study. In conclusion, it seems that the whole spectrum of cardiovascular complications in which retinal vessel alterations are implicated is only beginning to unfold. Future, prospective studies are warranted to reveal the exact role of retinal alterations in pregnancy, which could be of paramount clinical significance in diagnostic, prognostic, and therapeutic terms.
Disclosures None. Areti Triantafyllou 3rd Department of Internal Medicine Papageorgiou Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Panagiota Anyfanti 2nd Propedeutic Department of Internal Medicine Hippokration Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Stella Douma 3rd Department of Internal Medicine Papageorgiou Hospital Aristotle University of Thessaloniki Thessaloniki, Greece 1. Lupton SJ, Chiu CL, Hodgson LA, Tooher J, Ogle R, Wong TY, Hennessy A, Lind JM. Changes in retinal microvascular caliber precede the clinical onset of preeclampsia. Hypertension. 2013;62:899–904. 2. Triantafyllou A, Doumas M, Anyfanti P, Gkaliagkousi E, Zabulis X, Petidis K, Gavriilaki E, Karamaounas P, Gkolias V, Pyrpasopoulou A, Haidich AB, Zamboulis C, Douma S. Divergent retinal vascular abnormalities in normotensive persons and patients with never-treated, masked, white coat hypertension. Am J Hypertens. 2013;26:318–325. 3. Martell-Claros N, Blanco-Kelly F, Abad-Cardiel M, Torrejón MJ, Alvarez-Alvarez B, Fuentes ME, Ortega D, Arroyo M, Herraiz MA. Early predictors of gestational hypertension in a low-risk cohort. Results of a pilot study. J Hypertens. 2013;31:2380–2385. 4. Männistö T, Mendola P, Vääräsmäki M, Järvelin MR, Hartikainen AL, Pouta A, Suvanto E. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681–690. 5. Triantafyllou A, Zabulis X, Anyfanti P, Gavriilaki E, Gkaliagkousi E, Pyrpasopoulou A, Gkolias V, Triantafyllou G, Nikolaidou B, Zamboulis C, Aslanidis S, Douma S. Early and global estimation of microvascular target organ damage in hypertension by use of innovative software (abstract), 2nd International Medical Olympiad, 18–20 October 2013, Thessaloniki, Greece.
(Hypertension. 2014;63:e9.) © 2013 American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org
DOI: 10.1161/HYPERTENSIONAHA.113.02781
Downloaded from http://hyper.ahajournals.org/ e9 at McGill University Libraries on March 16, 2015
Assessment of Retinal Vasculature in Pregnancy: Unveiling the Complex Pathogenesis of Gestational Vascular Complications Areti Triantafyllou, Panagiota Anyfanti and Stella Douma Hypertension. 2014;63:e9; originally published online December 23, 2013; doi: 10.1161/HYPERTENSIONAHA.113.02781 Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hyper.ahajournals.org/content/63/2/e9
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Hypertension is online at: http://hyper.ahajournals.org//subscriptions/
Downloaded from http://hyper.ahajournals.org/ at McGill University Libraries on March 16, 2015
Assessment of Retinal Vasculature in Pregnancy: Unveiling the Complex Pathogenesis of Gestational Vascular Complications To the Editor: Lupton et al1 get our applause for their innovative study on retinal microvascular alterations and subsequent development of preeclampsia. Changes in retinal calibers are not only overt in the early stages of essential hypertension as shown previously by our group2 but are now for the first time implicated in the multifaceted hypertensive disorder of preeclampsia. However, data on blood pressure (BP) levels and unadjusted for BP retinal calibers are not provided by the authors. Although normotensive until 20 weeks of gestation, women who subsequently develop preeclampsia may lack the BP drop normally observed during first weeks of pregnancy and exhibit prehypertensive BP levels. Indeed, normal but higher BP levels during the first trimester are observed in women who later develop hypertensive pregnancy disorders, compared with uncomplicated pregnancy.3 Therefore, it would be rational to hypothesize that in the present study, BP differences might account for the differences in adjusted for BP retinal calibers. Likewise, could BP control after the establishment of preeclampsia after the 20th week account for the nonsignificant changes in cCRAE (corrected central retinal arterioral equivalent) at 29 weeks and cCRVE (corrected central retinal venular equivalent) at 29 and 38 weeks in the preeclampsia group? Another concern regards venular constriction in the preclinical stage of preeclampsia, represented by the adjusted for BP cCRVE. Potentially responsible mechanisms proposed by the authors, with inflammation being a common denominator, typically induce venular dilatation. Again, increased BP might account for this effect but data are lacking. Either way, the effect of inflammatory status preceding preeclampsia on retinal vascular calibers warrants thorough investigation. In addition, whether altered microcirculation mirrored in retinal vasculature precedes or succeeds the pathophysiological series leading to preeclampsia cannot be concluded because of lack of pregestational and postpartum measurements. Women in the preeclampsia group exhibited a worse cardiovascular risk profile, suggested by their increased age, body mass index, smoking habits, and previous history of hypertensive pregnancy disorders, which has been associated with increased risk of subsequent hypertension and cardiovascular disease.4 Both retinal microvascular alterations and hypertensive pregnancy disorders share mutual cardiovascular risk factors and are more frequently observed in individuals with an aggravated cardiovascular risk profile. Therefore, retinal microvascular alterations might have pre-existed in women who later developed preeclampsia. It could be said that hypertension and preeclampsia represent 2 sides of the same coin, which is an aggravated cardiovascular profile, repeatedly found to correlate or even be predicted by retinal microvascular alterations. Finally, we recently showed that a worse cardiovascular profile, estimated with Framingham risk score, may be predicted by the presence of both retinal vessel alterations and microalbuminuria.5
It would be interesting to know whether retinal arterioral diameters correlated with proteinuria, a key sign of preeclampsia, in the population of the present study. In conclusion, it seems that the whole spectrum of cardiovascular complications in which retinal vessel alterations are implicated is only beginning to unfold. Future, prospective studies are warranted to reveal the exact role of retinal alterations in pregnancy, which could be of paramount clinical significance in diagnostic, prognostic, and therapeutic terms.
Disclosures None. Areti Triantafyllou 3rd Department of Internal Medicine Papageorgiou Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Panagiota Anyfanti 2nd Propedeutic Department of Internal Medicine Hippokration Hospital Aristotle University of Thessaloniki Thessaloniki, Greece Stella Douma 3rd Department of Internal Medicine Papageorgiou Hospital Aristotle University of Thessaloniki Thessaloniki, Greece 1. Lupton SJ, Chiu CL, Hodgson LA, Tooher J, Ogle R, Wong TY, Hennessy A, Lind JM. Changes in retinal microvascular caliber precede the clinical onset of preeclampsia. Hypertension. 2013;62:899–904. 2. Triantafyllou A, Doumas M, Anyfanti P, Gkaliagkousi E, Zabulis X, Petidis K, Gavriilaki E, Karamaounas P, Gkolias V, Pyrpasopoulou A, Haidich AB, Zamboulis C, Douma S. Divergent retinal vascular abnormalities in normotensive persons and patients with never-treated, masked, white coat hypertension. Am J Hypertens. 2013;26:318–325. 3. Martell-Claros N, Blanco-Kelly F, Abad-Cardiel M, Torrejón MJ, Alvarez-Alvarez B, Fuentes ME, Ortega D, Arroyo M, Herraiz MA. Early predictors of gestational hypertension in a low-risk cohort. Results of a pilot study. J Hypertens. 2013;31:2380–2385. 4. Männistö T, Mendola P, Vääräsmäki M, Järvelin MR, Hartikainen AL, Pouta A, Suvanto E. Elevated blood pressure in pregnancy and subsequent chronic disease risk. Circulation. 2013;127:681–690. 5. Triantafyllou A, Zabulis X, Anyfanti P, Gavriilaki E, Gkaliagkousi E, Pyrpasopoulou A, Gkolias V, Triantafyllou G, Nikolaidou B, Zamboulis C, Aslanidis S, Douma S. Early and global estimation of microvascular target organ damage in hypertension by use of innovative software (abstract), 2nd International Medical Olympiad, 18–20 October 2013, Thessaloniki, Greece.
(Hypertension. 2014;63:e9.) © 2013 American Heart Association, Inc. Hypertension is available at http://hyper.ahajournals.org
DOI: 10.1161/HYPERTENSIONAHA.113.02781
Downloaded from http://hyper.ahajournals.org/ e9 at McGill University Libraries on March 16, 2015
Assessment of Retinal Vasculature in Pregnancy: Unveiling the Complex Pathogenesis of Gestational Vascular Complications Areti Triantafyllou, Panagiota Anyfanti and Stella Douma Hypertension. 2014;63:e9; originally published online December 23, 2013; doi: 10.1161/HYPERTENSIONAHA.113.02781 Hypertension is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 2013 American Heart Association, Inc. All rights reserved. Print ISSN: 0194-911X. Online ISSN: 1524-4563
The online version of this article, along with updated information and services, is located on the World Wide Web at: http://hyper.ahajournals.org/content/63/2/e9
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally published in Hypertension can be obtained via RightsLink, a service of the Copyright Clearance Center, not the Editorial Office. Once the online version of the published article for which permission is being requested is located, click Request Permissions in the middle column of the Web page under Services. Further information about this process is available in the Permissions and Rights Question and Answer document. Reprints: Information about reprints can be found online at: http://www.lww.com/reprints Subscriptions: Information about subscribing to Hypertension is online at: http://hyper.ahajournals.org//subscriptions/
Downloaded from http://hyper.ahajournals.org/ at McGill University Libraries on March 16, 2015
