Delayed retinal vein recovery responses indicate both non-adaptation to stress as well as increased risk for stroke: The SABPA study

Leoné Malan, Roland von Känel, Wayne Smith, Annemarie Wentzel, Carlien E. Myburgh, Nico T. Malan, Mark Hamer, Konstantin Kotliar, Roelof D. van Wyk, Gavin W. Lambert, Walthard Vilser, Tjalf Ziemssen, Markus P. Schlaich, Martin Magnusson, Hendrik S. Steyn

Research output: Contribution to journalArticlepeer-review

1 Citation (Web of Science)


Objectives: Low or high sympatho–adrenal–medullary axis (SAM) and hypothalamic–pituitary–adrenal axis (HPA) dysregulation reflect chronic stress. Retinal vessel dynamics may relate to SAM, HPA activity and stroke risk. Our objectives were therefore to assess the relationships between retinal vessel, SAM and HPA responses, and to determine stroke risk. Methods: A prospective bi-ethnic gender cohort (n = 275, 45 ± 9 years) was included. Urine/serum/saliva samples for SAM [norepinephrine:creatinine ratio (u-NE)] and HPA [adrenocorticotrophic hormone (ACTH), cortisol] were obtained at baseline, three-year follow up and upon flicker light-induced provocation. Diastolic ocular perfusion pressure was measured as a marker of hypo-perfusion. Retinal arterial narrowing and venous widening calibres were quantified from digital images in the mydriatic eye. A validated stress and stroke risk score was applied. Results: An interaction term was fitted for venous dilation in u-NE tertiles (p ≤ 0.05) and not in u-NE median/quartiles/ quintiles. Independent of race or gender, tertile 1 (low u-NE) had a 112% increase in u-NE, decreases in cortisol, and no changes in ACTH over three years (positive feedback). Tertile 3 (high u-NE) contradictorily had decreases in u-NE and cortisol, and increases in ACTH (negative feedback). In tertile 1, reduced arterial dilation, and faster arterial vasoconstriction and narrowing were related to higher SAM activity and hypo-perfusion (p ≤ 0.05), whereas delayed venous dilation, recovery and widening were related to cortisol hypo-secretion (p ≤ 0.05). In tertile 1, delayed venous recovery responses predicted stress and stroke risk [odds ratio 4.8 (1.2–19.6); p = 0.03]. These associations were not found in u-NE tertiles 2 and 3. Conclusions: In response to low norepinephrine, a reflex increase in SAM activity occurred, enhancing arterial vasoconstriction and hypo-perfusion. Concomitant HPA dysregulation attenuated retinal vein vasoactivity and tone, reflecting delayed vein recovery responses and non-adaptation to stress. These constrained vein recovery responses are indicative of increased chronic stress and stroke risk.

Original languageEnglish
Pages (from-to)5-16
Number of pages12
JournalCardiovascular Journal of Africa
Issue number1
Publication statusPublished - Feb 2021


Dive into the research topics of 'Delayed retinal vein recovery responses indicate both non-adaptation to stress as well as increased risk for stroke: The SABPA study'. Together they form a unique fingerprint.

Cite this