Severe hypertension: Grade III and IV retinopathy were associated with a worse prognosis at 20 years.

Clinical bottom line (level 4)

  1. In severe hypertension, patients with grade III and IV hypertensive retinopathy were more likely to die (NNF = 2 for 10 years) (NNF = 4 for 20 years) .
Breslin et al: Journal of the American Medical Association 1966; 195: 335-338
Expires August 2003

The study

Inception cohort study with objective outcomes, not adjusted for confounding factors, not validated in an independent set of patients.

Setting: university hospital, USA

631 patients (aged ?, 55% male) diagnosed in 1940 with essential hypertension


86% followed for 20 years
Outcomes studied:
  • Grade I retinopathy survival at 20 years
  • Grade II retinopathy survival at 20 years
  • Grade III retinopathy survival at 20 years
  • Grade IV retinopathy survival at 20 years
  • death at 10 years
  • death at 20 years

    • No details of inclusion or exclusion criteria were given.
    • exposure:
      • Keith-Wagener classification: grade- retina; changes (viewed by ophthalmologist)
      • Grade I- minimal changes; no haemorrhages
      • Grade II- sclerosis of arterioles +/- haemorrhages, no exudates
      • Grade III- exudates +/- haemorrhages
      • Grade IV- papilloedema

    The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)
    Grade I retinopathy survival at 20 years 20 years / 46%
    (% to %)
    Grade II retinopathy survival at 20 years 20 years / 21%
    (% to %)
    Grade III retinopathy survival at 20 years 20 years / 5%
    (% to %)
    Grade IV retinopathy survival at 20 years 20 years / 4%
    (% to %)
    death at 10 years 20 years / %
    (% to %)
    death at 20 years 20 years / %
    (% to %)

    prognostic factor for
    death at 10 years     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    grade III, IV 20 years 2.19
    (1.90 to 2.52)     		2
    (2 to 3)

    prognostic factor for
    death at 20 years     		time to outcome unadjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    grade III, IV 20 years 1.33
    (1.24 to 1.44)     		4
    (3 to 6)

    Comments

    1. No account was made for other prognostic factors including amount of time the patients was hypertensive prior to diagnosis, age, presenting co-morbidity and outcome measures (presence of heart and renal disease), thus reducing the validity of this study.
    2. The study was performed during poor or no treatment of hypertension.

    Citation

    1. Breslin DJ, et al: Prognostic importance of ophthalmoscopic findings in essential hypertension. Journal of the American Medical Association 1966; 195: 335-338
    Contributor: Nick Shenker and Chris Ball, August 2000
    Reviewer:

    Clinical Question.
    Patient severe hypertension
    Intervention or Exposure risk factors
    Outcome hypertensive retinopathy