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The eyes are the mirror of the heart: role of retinal microvascular abnormalities in predicting long‐term risk of heart failure

Heart failure (HF) portends high mortality ranging ∼6–9% annually, despite continuous progress in treatment.1 The poor prognosis of HF underscores the importance of risk stratification and primary prevention. Traditional risk factors [e.g. coronary artery disease (CAD), hypertension, diabetes, smoking, and obesity] account for most of the population-attributable risk for HF.2 However, there is a continuous interest in markers of an early disease process that would refine HF risk stratification. The retinal fundoscopy offers a unique opportunity for non-invasive, in vivo assessment of the microvascular network and its disorders. Existing data suggest that alterations in the retinal microvasculature provide a surrogate for the pathological processes occurring in other vascular beds of interest, including the heart.3,4 Indeed, retinal microvascular abnormalities have been associated with more severe CAD5 and incident myocardial infarction, in particular among women.6 In addition, several studies have found an association between retinal microvascular abnormalities and prevalent HF of either ischaemic or non-ischaemic aetiology,7,8 with a suggestion of a stronger association in patients with diabetes.9 However, the predictive value of retinal microvascular abnormalities for incident HF has been less well defined. This important issue has been addressed in the study by Chandra et al.10 published in the current issue of the Journal. This study assessed the association between diameters of central retinal arterioles and venules and the long-term risk of incident HF among 10 692 individuals without baseline cardiovascular (CV) disease (i.e. CAD, HF, or stroke) from the Atherosclerosis Risk in Communities (ARIC) Study. Digitized photographs of the retina, taken between