Diabetic retinopathy, a microvascular complication of diabetes, is a significant marker of systemic vascular damage, which has been linked to increased cardio-renal disease risks. This study investigates the impact of diabetic retinopathy on all-cause mortality and adverse cardiovascular and renal outcomes in patients with established heart failure with reduced ejection fraction (HFrEF) using real-world data.

Using data from January 1, 2012, to December 31, 2021, we conducted a propensity-matched analysis of two cohorts of patients with HFrEF and diabetes without chronic kidney disease (CKD, estimated glomerular filtration rate >60 mL/min/1.73 m²), differentiated by the presence or absence of diabetic retinopathy diagnosis in the TriNetX platform. The primary outcome was all-cause mortality, with secondary outcomes including acute HF, CKD progression, major adverse cardiovascular events, stroke, in-patient hospitalizations, venous thromboembolism (VTE), and peripheral arterial disease (PAD).

Following propensity score matching across demographics and clinical variables, each cohort included 15,218 patients. Acute HF was more common in the retinopathy vs non-retinopathy cohort (HR: 1.13, 95 % CI: 1.06–1.20). Results also showed significant increased risks for CKD progression (HR: 1.39, 95 % CI: 1.30–1.50), stroke (HR: 1.18, 95 % CI: 1.08–1.28), as well as PAD (HR: 1.58, 95 % CI: 1.42–1.76) for patients with diabetic retinopathy.

Diabetic retinopathy is associated with an increased risk of adverse cardio-renal outcomes in patients with established HFrEF.

Diabetic retinopathy

Heart failure

Chronic kidney disease

Prognosis

© 2025 The Author(s). Published by Elsevier Inc.