Acute nonarteritic CRAO: A red flag for cardiovascular risk factors

Take-home message: Most patients with acute nonarteritic central retinal artery occlusion have a cardiovascular risk profile, and a comprehensive medical evaluation can uncover more risk factors.

By Lynda Charters; Reviewed by Nicholas Feltgen, MD, and Amelie Pielen, MD

Hannover, Germany-New information has emerged that is helpful in the treatment of patients with acute nonarteritic central retinal artery occlusion (CRAO), namely, that undiagnosed vascular risk factors, the most important of which is ipsilateral carotid artery stenosis, have been identified in more than three quarters of the patients with nonarteritic CRAO.

The study conducted in Germany has confirmed what has long been recognized ‒ a connection between CRAO and cardiovascular risk factors. This is an important finding considering that acute nonarteritic CRAO is a leading cause of irreversible loss of vision. The results support previous studies that found the life expectancy of patients with CRAO is 10 years less compared with healthy controls.

The investigators in the European Assessment Group for Lysis in the Eye (EAGLE) study, a prospective, randomized clinical trial, analyzed cardiovascular risk factors and concomitant diseases identified in 84 patients with nonarteritic CRAO within 1 month of the occlusion.

The patients underwent a physical evaluation that included echocardiography, electrocardiography, measurement of blood pressure and pulse rate, carotid Doppler ultrasonography, urinanalysis, and determination of the body mass index (BMI), according to Amelie Pielen, MD, and Nicholas Feltgen, MD, who reported the results for the EAGLE study. The investigators published their findings in Ophthalmology (2015;122:1881-1888).

In addition to the physical examination, the patients answered a standardized questionnaire that recorded their medical history to identify any contraindications to fibrinolysis, a study treatment.

Of the 84 patients, 77 patients (54 men, 23 women; mean age, 62.2 years; range, 24 - 75 years) completed the medical and neurologic examinations. The investigators reported that 11 (14%) patients had one or more cardiovascular risk factors or events in their medical histories; 41 (53%) patients had the same and at least one additional risk factor that was also newly diagnosed during the evaluation; and 19 (25%) patients had no cardiovascular risk factors or events in the medical history, and at least one risk factor was newly diagnosed.

“After standardized medical and neurologic examination, cardiovascular risk factors or events were newly diagnosed in a total of 60 patients (78%; 95% confidence interval, 67%-87%). In total, 71 (92%) patients had cardiovascular risk factors or events, and 60 (78%) patients had more than one risk factor or event,” the study reported.

Most relevant risk factors

In the EAGLE study, arterial hypertension was one of the most common risk factors seen in 56 (73%) patients. In 44 of the 56 patients, the medical history contained the diagnosis but it had not been diagnosed previously in 12 patients, Dr. Pielen commented. She is a consultant at the University Eye Hospital, Hannover Medical School, Hannover, Germany.

Elevated BMIs were found frequently. Of 55 patients in whom the BMIs were determined, 45 (82%) had a BMI that exceeded 25 kg/m²; the BMI in 15 (27%) patients was over 30 kg/m².

Smoking was another common risk factor. Almost half of patients reported that they were former smokers or still actively smoked.

Finally, one of the most important findings from this study, the analysis showed, was what the investigators described as the “remarkable percentage of hemodynamically relevant ipsilateral carotid artery stenosis” that they identified. Thirty-one (40%) patients had carotid artery stenosis with at least 70% narrowing, which the investigators noted, is a “much higher rate” than those reported in previous trials in which the percentages ranged from 15% to 24%. Eleven patients had a stroke, and in five of them the stroke occurred within 4 weeks after the CRAO.

Major study findings

There were three important findings in this study, Dr. Pielen pointed out. The first was that cardiovascular risk factors are frequent findings in patients with CRAO and comprehensive evaluations identify a large number of patients who have risk factors that had never been identified previously.

The second important finding was that among the newly identified risk factors, ipsilateral carotid artery stenosis occurred very frequently, but had been identified before in only 3% of patients before the development of CRAO.

Finally, carotid ultrasonography seemed to be the most important diagnostic tool in patients with CRAO.

Dr. Pielen summarized, “…we confirmed a cardiovascular risk profile in most acute nonarteritic CRAO patients, and in 78%, prompt work-up showed new risk factors. The most significant finding was ipsilateral carotid artery stenosis meeting criteria for revascularization in 40% of CRAO patients. We consider CRAO patients at high risk for future vascular events and recommend a comprehensive diagnostic work-up in all patients with CRAO.”

Nicholas Feltgen, MD

E: Nicolas.feltgen@med.uni-goettingen.de

Amelie Pielen, MD

E: Pielen.Amelie@mh-hannover.de

Neither Dr. Feltgen nor Dr. Pielen indicated any financial interest in the subject matter.