Better-eye visual acuity as a functional marker of long-term cardiovascular risk: a prospective cohort study

Background Visual acuity (VA) and cardiovascular disease are major health concerns and are closely linked to aging, functional decline, and systemic vascular health. Although poor VA has been associated with mortality and adverse health outcomes, its association with incident major adverse cardiovascular events (MACE) remains inadequately characterized. Objectives This study aimed to investigate the association between better-eye logMAR VA and incident MACE in a large prospective cohort. Methods This prospective cohort study included 111,446 participants with bilateral VA data and no prevalent MACE at baseline. Better-eye logMAR VA was analyzed as a continuous variable and by cohort-specific quartiles. Incident MACE was defined as the earliest occurrence of acute myocardial infarction, heart failure, ischemic stroke, or cardiovascular death. Cox proportional hazards models were used to estimate HRs and 95% CIs, with adjustment for demographic, lifestyle, socioeconomic, clinical, physical activity, and kidney function variables. Dose-response analysis, subgroup analysis, competing-risk analysis, and sensitivity analyses were performed to further evaluate the association. Results Among 111,446 participants, mean age was 56.67 years and 55.4% were women. During a median follow-up of 14.17 years, 8,275 incident MACE events occurred. In the fully adjusted model, each 0.1-unit increase in better-eye logMAR visual acuity, indicating worse vision, was associated with a 5.7% higher MACE risk (HR, 1.057; 95% CI, 1.042–1.071). Compared with Q1, the HR was 1.249 (95% CI, 1.175–1.329) for Q4. Associations were directionally consistent across acute myocardial infarction, heart failure, ischemic stroke, and cardiovascular death. Restricted cubic splines showed an overall association ( P overall < 0.001), without evidence of nonlinearity ( P nonlinearity = 0.098). Findings were consistent in survival-compatible imputation and landmark analyses. Conclusions Worse better-eye VA was independently associated with higher long-term risk of incident MACE. Visual acuity may represent a readily available functional marker of cardiovascular vulnerability, although its incremental predictive value and clinical utility require further evaluation.