Assessing the retinal microvasculature in heart failure: A systematic review and possible clinical implications

Despite an extensive armamentarium, the long-term prognosis of heart failure remains poor, and its pathophysiology is still not fully understood. Microvascular function is impaired early in the development of HF and linked to disease progression. Retinal imaging provides a unique opportunity for fast, non-invasive and affordable detection of early systemic microvascular disease.

To provide a systematic overview of current literature regarding retinal microvascular changes in HF.

A literature search was performed using MEDLINE, EMBASE, Web of Science and Cochrane Library (Registration number: INPLASY202450114). Studies on retinal microvascular changes, visualized by fundus photography, adaptive optics, optical coherence tomography, scanning laser Doppler flowmetry and dynamic vessel analysis in patients with HF were included.

Twenty-four articles were included for qualitative analysis. Compared to healthy controls, patients with HF consistently exhibited reduced flicker light-induced dilation of retinal arterioles and venules, as well as decreased vessel density around the optic nerve head. More limited evidence suggests an increase in arteriolar wall thickness and wall cross-sectional area. Findings supporting other structural changes in the retinal microvessels were inconsistent. The pathophysiology behind retinal vascular abnormalities in HF and their correlation with HF severity remain incompletely understood. Nevertheless, retinal imaging holds promise for identifying individuals at risk of developing HF and predicting prognosis. Overall, analysis of retinal microvascular structure and function could serve as a valid surrogate marker for future interventional studies in HF.

This review provides a systematic overview on retinal imaging as a promising tool in the prevention, risk stratification and management of HF, and as a surrogate marker in clinical trials.