Prevalence, characteristics, and outcome of subclinical vasculitis in polymyalgia rheumatica: a retrospective cohort study

Incidence of aortic aneurysm, dissection, or rupture among patients with polymyalgia rheumatica and giant cell arteritis

BACKGROUND

Patients with polymyalgia rheumatica (PMR) may have subclinical large vessel vasculitis. We compared the incidence of aortic complications in PMR and giant cell arteritis (GCA) to the general population.

METHODS

A retrospective cohort study was performed of patients with PMR and GCA identified by ≥2 ICD-9/ICD-10-CM diagnostic codes and concurrent corticosteroid treatment in the US-based TriNetX database (2000-2024). Matched general population controls were identified (1:3 ratio). The primary outcome, aortic complications, was a composite of aortic aneurysm and dissection/rupture. Adjusted hazard ratios (aHR) were calculated using Cox proportional cause-specific hazard models with PMR as the referent category.

FINDINGS

Of 57,336 patients, 17,327 had PMR, 4,734 had GCA, and 35,275 were matched controls. Median follow-up time was 3.74 years (interquartile range, 1.8-6.4). The incidence rate of any aortic complication per 1,000 person-years was highest for GCA (11.69), followed by PMR (6.78) and the general population (5.09). Compared to patients with PMR, patients with GCA had a higher risk of any aortic complication (aHR 1.87, 95 % confidence interval (CI) 1.58-2.21); the general population risk was similar (aHR 0.95, 95 % CI 0.84-1.06). In a sensitivity analysis, patients with PMR who later developed GCA had a risk similar to those initially diagnosed with GCA (aHR 0.85, 95 % CI 0.60-1.19).

INTERPRETATION

Patients with PMR had a similar risk of large vessel complications compared to the general population and a lower risk compared to those with GCA. These results do not support screening for aortic inflammation among patients with PMR who lack features of GCA.

A history of polymyalgia rheumatica: a narrative review

Polymyalgia rheumatica (PMR) is characterized by stiffness and pain in the shoulders, hips and neck and presents most commonly in the eighth decade. It can coexist with giant cell arteritis and the two diseases may share some pathophysiological mechanisms. This narrative review considers present-day ideas about PMR in a historical context, from the first names and descriptions of this disease entity, via successive generations of classification criteria sets, and finally to implications for clinical diagnosis. The characteristic distribution of musculoskeletal inflammation in PMR and its relationship to vasculitic and synovitic diseases have framed the way that PMR is described, classified, diagnosed and treated. A response to glucocorticoids is not specific to PMR and so it is important for rheumatologists to support general practitioners in making a definite diagnosis. Multi-stakeholder collaboration will improve current pathways for fast, accurate diagnosis and safe and effective treatment.

Broadening the clinical spectrum of giant cell arteritis: from the classic cranial to the predominantly extracranial pattern of the disease

INTRODUCTION

Giant cell arteritis (GCA) is a large vessel (LV) vasculitis that affects people aged 50 years and older. Classically, GCA was considered a disease that involved branches of the carotid artery. However, the advent of new imaging techniques has allowed us to reconsider the clinical spectrum of this vasculitis.

AREASCOVERED

This review describes clinical differences between patients with the cranial GCA and those with a predominantly extracranial LV-GCA disease pattern. It highlights differences in the frequency of positive temporal artery biopsy depending on the predominant disease pattern and emphasizes the relevance of imaging techniques to identify patients with LV-GCA without cranial ischemic manifestations. The review shows that so far there are no well-established differences in genetic predisposition to GCA regardless of the predominant phenotype.

EXPERT COMMENTARY

The large branches of the extracranial arteries are frequently affected in GCA. Imaging techniques are useful to identify the presence of 'silent' GCA in people presenting with polymyalgia rheumatica or with nonspecific manifestations. Whether these two different clinical presentations of GCA constitute a continuum in the clinical spectrum of the disease or whether they may be related but are definitely different conditions needs to be further investigated.