Inpatient prevalence, burden and comorbidity of Takayasu's arteritis: Nationwide inpatient sample 2013–2014

Aneurysmal Disease in Patients With Takayasu Arteritis

OBJECTIVE

Takayasu arteritis (TA) leads to stenotic disease. Aneurysmal lesions are rarer. This study assessed the main characteristics of aneurysmal disease in a Canadian cohort of patients with TA.

METHODS

This monocentric retrospective study included patients with TA followed at the Mount Sinai Hospital Vasculitis Clinic in Toronto. Diagnosis of TA was based on clinical findings and/or satisfied the 1990 American College of Rheumatology classification criteria.

RESULTS

Seventy-four patients were included. At any time, aneurysmal disease was found in 23 (31%) patients. Median disease duration was 9.0 (IQR 7.0-19.0) years. Prior hypertension (P = 0.02), fever (P = 0.04), and seizure disorders (P = 0.03) were more common. Limb claudication was less frequent (P = 0.01). Persistent and/or new aneurysms were demonstrated in 22/23 patients at follow-up. Thoracic aorta aneurysm (13/22) was most common, followed by abdominal aorta (8/22), subclavian (7/22), and carotid (6/22) artery disease. Aortic valve regurgitation was more frequent (9/23 vs 3/48; P = 0.001). Twenty-one patients had been treated with glucocorticoids (median 6.1 years [IQR 3.7-8.1]). Methotrexate, azathioprine, and leflunomide were repeatedly used. Infliximab (7/23) was used more often (P = 0.04), whereas tocilizumab was received by only 4 patients with aneurysmal disease (P = 0.01). Patients with aneurysms suffered more frequent relapses (2.0 [IQR 0.0-4.0] vs 1.0 [IQR 0.0-2.0], P = 0.04).

CONCLUSION

Aneurysmal disease was found in a significant proportion of patients with TA. Given that aneurysms may carry a risk of rupture, and are associated with a higher rate of relapse, this finding should be reported systematically in TA studies.

Cardiovascular Disease in Large Vessel Vasculitis: Risks, Controversies, and Management Strategies

Takayasu's arteritis (TAK) and giant cell arteritis (GCA) are the 2 most common primary large vessel vasculitides (LVV). They share common vascular targets, clinical presentations, and histopathology, but target a strikingly different patient demographic. While GCA predominantly affects elderly people of northern European ancestry, TAK preferentially targets young women of Asian heritage. Cardiovascular diseases (CVD), including ischemic heart disease, cerebrovascular disease, aortic disease, and thromboses, are significantly increased in LVV. In this review, we will compare and contrast the issue of CVD in patients with TAK and GCA, with respect to prevalence, risk factors, and mechanisms of events to gain an understanding of the relative contributions of active vasculitis, vascular damage, and accelerated atherosclerosis. Controversies and possible mitigation strategies will be discussed.

Relationship Between Cerebrovascular Diseases and Vasculitis: A Cross-Sectional Nationwide Inpatient Study

Objectives

To evaluate the risk factors and hospitalization outcomes for cerebrovascular diseases (CVD) in patients with vasculitis.

Methods

We conducted a cross-sectional study using the Nationwide Inpatient Sample (NIS), 2019. We included 26,855 adults (aged 18 to 65 years, average age 48.57 ± 12.79 years) with a co-diagnosis of vasculitis, and the sample was divided by the primary diagnosis of CVD (N = 670, 2.5%). A demographic-adjusted logistic regression model was used to evaluate the odds ratio (OR) of association with CVD in patients with vasculitis by comparing it to the non-CVD cohort.

Results

The majority of the vasculitis patients with CVD were elders (51 to 65 years, 46%), females (62%), and whites (52%). There was a significant difference in the geographic distribution of CVD with vasculitis with the highest prevalence in the South Atlantic (23%) and Middle Atlantic (16%), and the lowest in the Mountain (4%) and New England (2%). Vasculitis patients with comorbid lymphoma (OR 2.46, P<0.001), peripheral vascular diseases (PVD (OR 1.54, P<0.001)), and complicated hypertension (OR 1.31, P<0.001) were associated with increasing the likelihood for CVD-related hospitalization. The mean length of stay was 13 days and the mean cost was $169,440 per CVD-related hospitalization in vasculitis patients. Cerebrovascular diseases in patients with vasculitis resulted in a major loss of body functioning (80%) leading to adverse disposition including transfer to a skilled nursing facility/intermediate care facility (22%) and requiring home health care (13%).

Conclusion

The prevalence of CVD-related hospitalization in vasculitis patients was 2.5% and females were observed to be at higher risk. Comorbid lymphoma, PVD, and hypertension further increase the risk for CVD with vasculitis. They have a higher loss of functioning that affects patient quality of life and require increased care after hospital discharge.

Cerebrovascular Ischemic Events in Patients With Takayasu Arteritis

BACKGROUND

Takayasu arteritis (TA) is a large vessel vasculitis that may complicate with cerebrovascular ischemic events. The objective was to describe clinical and vascular features of TA patients with cerebrovascular ischemic events and to identify risk factors for these events.

METHODS

We analyzed the prevalence and type of stroke/transient ischemic attack (TIA), factors associated with cerebrovascular ischemic events, and stroke-free survival in a large cohort fulfilling the American College of Rheumatology or Ishikawa criteria of TA.

RESULTS

Among 320 patients with TA (median age at diagnosis, 36 [25-47] years; 261 [86%] women), 63 (20%) had a stroke (n=41; 65%) or TIA (n=22; 35%). Ischemic event localized in the carotid territory for 55 (87%) patients and the vertebral artery territory in 8 (13%) patients. Multiple stenosis were observed in 33 (52%) patients with a median number of stenosis of 2 (minimum, 0 to maximum, 11), and aneurysms were observed in 10 (16%) patients. A history of stroke or TIA before TA diagnosis (hazard ratio [HR], 4.50 [2.45-8.17]; P<0.0001), smoking (HR, 1.75 [1.01-3.02]; P=0.05), myocardial infarction history (HR, 0.21 [0.05-0.89]; P=0.039), thoracic aorta involvement (HR, 2.05 [1.30-3.75]; P=0.023), time from first symptoms to diagnosis >1 year (HR, 2.22 [1.30-3.80]; P=0.005), and aspirin treatment (HR, 1.82 [1.04-3.19]; P=0.035) were associated with cerebrovascular ischemic event. In multivariate analysis, time from first symptoms to TA diagnosis >1 year (HR, 2.16 [1.27-3.70]; P=0.007) was independently associated with cerebrovascular ischemic events in patients with TA. The HR for cerebrovascular ischemic event in patients who already experienced a stroke/TIA was 5.11 (2.91-8.99; P<0.0001), compared with those who had not.

CONCLUSIONS

Carotid stroke/TIA is frequent in TA. We identified factors associated with cerebrovascular ischemic events.

Cardiovascular events and the role of accelerated atherosclerosis in systemic vasculitis

The spectrum of inflammatory blood vessel diseases includes both atherosclerosis and the primary systemic vasculitides. Although the inciting triggers differ, significant overlap exists in the mechanisms that contribute to sustained inflammation and vascular damage in both entities. With improvement in therapeutics to control acute vasculitis leading to longer survival, cardiovascular morbidity and mortality has emerged as the leading cause of death for vasculitis patients. Cardiovascular events likely occur as a consequence of vasculitis, vascular damage from prior inflammation causing a sustained procoagulant state, and accelerated atherosclerosis. In this review, we discuss the latest evidence regarding risk of cardiovascular events in patients with major forms of primary systemic vasculitis, and review the mechanisms by which accelerated atherosclerosis may occur.

Surgical Treatment in Patients With Aortic Regurgitation Due to Takayasu Arteritis

BACKGROUND

Aortic regurgitation is a common complication in patients with Takayasu arteritis. Severe aortic regurgitation requires surgical treatment. We investigated the outcomes of aortic valve replacement (AVR) and composite graft replacement (CGR) in patients with Takayasu arteritis and aortic regurgitation.

METHODS

We retrospectively reviewed the data from 41 patients with Takayasu arteritis and aortic regurgitation treated by AVR (n = 23) and CGR (n = 18) from January 1992 to December 2016.

RESULTS

The mean age at operation was 40.3 years, and 61.0% were women. Concurrent procedures were performed in 43.9% of patients. The preoperative aortic root diameter in the AVR and CGR groups was 41.5 ± 7.9 and 47.8 ± 9.5 mm, respectively. The cardiopulmonary bypass time was longer in the CGR group (140.2 ± 44.8 minutes) than in the AVR group (105.2 ± 32.5 minutes). No in-hospital death occurred. During a median follow-up of 6.6 years (interquartile range, 0.6-9.4) we observed 10 patients with composite adverse events in the AVR group (1 death, 3 reoperations, 3 residual ascending aorta aneurysms, 6 paravalvular leaks, and 1 valve detachment) and 2 composite events in the CGR group (2 deaths and 1 paravalvular leak). The unadjusted 5-year event-free rate was 55.8% and 91.7% in the AVR and CGR groups, respectively (log-rank P < .05). CGR was associated with nominally lower events on adjusted analysis (hazard ratio, 4.212; 95% confidence interval [0.910, 19.509]; P = .066).

CONCLUSIONS

Paravalvular leak was the main postoperative complication. CGR was associated with nominally fewer adverse events.