Survival and death causes of patients with giant cell arteritis in Western Norway 1972-2012: a retrospective cohort study

Factors predicting death and cancer in patients with giant cell arteritis in Western Norway 1972-2012: a retrospective observational cohort study

Objectives

Evidence as to whether or not giant cell arteritis (GCA) confers added risk of cancer or death is conflicting. Our aim was to identify factors predicting death or cancer in a large Norwegian GCA-cohort.

Methods

This is a retrospective observational cohort study including patients diagnosed with GCA in Western Norway during 1972-2012. Patients were identified through computerized hospital records using the International Classification of Diseases coding. Medical records were reviewed and data about registered deaths and cancer occurrences were extracted from the Norwegian Cause of Death Registry and the Cancer Registry of Norway. We investigated predicting factors using Cox proportional hazards regression.

Results

We identified 881 cases with a validated diagnosis of GCA (60% biopsy-verified). 490 patients (56%) died during the study period. Among 767 patients with no registered cancer prior to GCA diagnosis, 120 (16%) were diagnosed with cancer during the study period. Traditional risk factors were the main predictors of death; age at time of GCA-diagnosis [hazard ratio (HR) 2.81], smoking (HR 1.61), hypertension (HR 1.48) and previous cardiovascular disease (HR 1.26). Hemoglobin (Hb) level was also associated with risk of death with increasing Hb-levels at time of GCA-diagnosis indicating decreased risk of death (HR 0.91). Other GCA-related factors were not predictive of death. We did not identify any predictors of cancer risk.

Conclusion

In our cohort of GCA-patients, the risk of death was predominantly predicted by age and traditional risk factors. We found no significant associations with regards to the risk of incident cancer.

Race and Gender on the Mortality of Giant Cell Arteritis in Hospitalized Patients: A 15-Year National Inpatient Study

BACKGROUND

Critical appraisal of mortality in giant cell arteritis (GCA) through a racial lens is imperative as gender and racial disparities remain a global healthcare concern.

OBJECTIVE

To analyze the impact of race and gender on the mortality of GCA in United States (US)-hospitalized patients.

METHODS

In this retrospective cohort study, the National Inpatient Sample (NIS) database from January 2003 to December 2018 was searched to identify all patients aged >18 years hospitalized with giant cell arteritis. Patients' baseline characteristics were summarized using descriptive statistics. Inferential statistics were done for categorical and continuous variables. Multivariate logistic regression, adjusting for patient and hospital-level cofounders was performed to find an association between race and outcomes of interest.

RESULTS

Over the 15-year study period, a total of 8,352 patients (72.7% White, 14.5% Black or African American, 7.6% Hispanic, 2.2% Asian, 0.4% Alaska Native, and 2.6% under-represented populations) were hospitalized for GCA. The mean age at diagnosis was 73.6 ± 0.12 years. Women represented 71.9% of GCA patients and had a lower risk of mortality (OR 0.463, 95% CI: 0.235 - 0.912, p <0.05). Patients with GCA were hospitalized for an average of 4.64 days ± 0.04 days and 0.55% died. The mortality rate was lowest in Black or African American (0.1%) populations and highest among Alaska Native patients (8%). Mortality was 68% lower in those who had temporal artery biopsy (OR 0.32, 95% CI: 0.16-0.64, p <0.05).

CONCLUSION

GCA disproportionally affected female patients, but mortality was higher in male patients. Alaska Native patients had the least number of hospitalizations but the highest in-hospital mortality rate. Black or African Americans had the lowest mortality rate.

Giant Cell Arteritis: A Case-Based Narrative Review of the Literature

Purpose of Review

Giant cell arteritis (GCA) is a chronic, inflammatory condition, primarily affecting the medium and larger arteries. The purpose of this narrative review is to describe GCA in the context of headache and facial pain, based on a case and the available current literature. Understanding the etiology, pathophysiology, the associated conditions, and the differential diagnoses is important in managing GCA.

Recent Findings

In a patient presenting with unilateral facial/head pain with disturbances of vision, GCA should be considered in the differential diagnosis. There is an association of GCA with several comorbid conditions, and infections including coronavirus-19 (COVID-19) infection. Management of GCA primarily depends upon the identification of the affected artery and prompt treatment. Permanent visual loss and other serious complications are associated with GCA.

Summary

GCA is characterized by robust inflammation of large- and medium-sized arteries and marked elevation of systemic mediators of inflammation. An interdisciplinary approach of management involving the pertinent specialties is strongly recommended.

Cardiovascular lesions in giant cell arteritis

Introduction

Giant cell arteritis (GCA) is a systemic vasculitis that affects large vessels. Cardiovascular complications that develop with GCA have high morbidity and can be fatal. The aim of this work was to discuss epidemiology, clinical picture, etiopathology and risk of development of cardiovascular complications in GCA.

Material and methods

A literature review was performed for 2002 to 2021 using PubMed and Medline scientific search databases. The following keywords were used to search academic journal databases: "giant cell arteritis", "heart attack", "cardiovascular system", "aortic aneurysm", "coronary heart disease", "aortic dissection", "myocardium" and "stroke". Articles written in languages, other than English, were excluded.

Results

The analysis of studies showed an increased risk of an aneurysm, aortic dissection, coronary heart disease, cerebrovascular events, and peripheral artery disease in patients with GCA. This was not surprising as it has been shown that, cardiovascular complications worsens the prognosis in GCA. According to the results of observations and cited studies the most significant risk of cardiovascular complications was observed in the first year following the diagnosis of GCA.

Conclusions

Patients with GCA have an increased risk of cardiovascular disease, but research data/findings are somewhat conflicting, and there is limited information/knowledge on how to treat the patients. Awareness of the risk of cardiovascular disease in GCA is essential, and monitoring these potentially fatal consequences is mandatory in patients with GCA. It is critical to be aware of the danger of cardiovascular illness in GCA patients and to keep track of these potentially deadly outcomes.

Real-life analysis of the causes of death in patients consecutively followed for giant cell arteritis in a French centre of expertise

OBJECTIVES

To describe, in a real-life setting, the direct causes of death in a cohort of consecutive patients with GCA.

METHODS

We retrospectively analysed the deaths that occurred in a cohort of 470 consecutive GCA patients from a centre of expertise between January 2000 and December 2019. Among the 120 patients who died, we retrieved data from the medical files of 101 patients.

RESULTS

Cardiovascular events were the dominant cause of death (n = 41, 41%) followed by infections (n = 22, 22%), geriatric situations (i.e. falls or senile deterioration; n = 17, 17%) and cancers (n = 15, 15%). Patients in each of these four groups were compared with the other deceased patients pooled together. Patients who died from cardiovascular events were more frequently male (46 vs 27%; P = 0.04) with a past history of coronary artery disease (29 vs 8%; P = 0.006). Patients who died from infections mostly had ongoing glucocorticoid treatment (82 vs 53%; P = 0.02) with higher cumulative doses (13 994 vs 9150 mg; P = 0.03). Patients who died from geriatric causes more frequently had osteoporosis (56 vs 17%; P = 0.0009) and had mostly discontinued glucocorticoid treatment (76 vs 33%; P = 0.001). The predictive factors of death in multivariate analysis were a history of coronary disease [hazard ratio (HR) 2.39; 95% CI 1.27, 4.21; P = 0.008], strokes at GCA diagnosis (HR 2.54; 95% CI 1.05, 5.24; P = 0.04), any infection during follow-up (HR 1.93; 95% CI 1.24, 2.98; P = 0.004) and fever at GCA diagnosis (HR 1.99; 95% CI 1.16, 3.28; P = 0.01).

CONCLUSION

Our study provides real-life insight on the cause-specific mortality in GCA patients.

Aortitis: an update

PURPOSE OF REVIEW

Aortitis is the inflammation of the aorta due to various causes. Clinical presentations vary as well as the imaging findings. Exact pathogenetic mechanisms or triggering factors, as well as the best diagnostic and monitoring modalities and treatment strategies, are yet to be elucidated. We reviewed recent studies in aortitis and associated diseases.

RECENT FINDINGS

Multiple cohort studies reporting long-term outcomes in patients with noninfectious aortitis were recently published. Comparative features of isolated aortitis were described. Six angiographic clusters for giant cell arteritis and Takayasu have been identified. New classification criteria have been proposed for IgG4-related disease by a data-driven method. The ultrasonographic slope sign and a halo score were described as specific imaging parameters in giant cell arteritis. The promising role of PET-computed tomography, not only in the diagnosis of aortitis but also in monitoring disease activity, has been noted. Results of in-vitro studies on Janus kinase (JAK)/signal transducers and activators of transcription and mammalian target of rapamycin (mTOR) pathways, comparative studies with leflunomide as an induction therapy, and a long-term follow-up study with tocilizumab may contribute to the management of Takayasu arteritis.

SUMMARY

An impressive number of studies have addressed aortitis in recent years. However, there still is a lack of robust data on causes, monitoring disease activity by imaging and biomarkers, and drugs providing steroid-free remission in noninfectious aortitis.

The Incidence and Predictors of Solid- and Hematological Malignancies in Patients with Giant Cell Arteritis: A Large Real-World Database Study

BACKGROUND

The association between giant cell arteritis (GCA) and malignancies had been widely investigated with studies reporting conflicting results. Therefore, in this study, we aimed to investigate this association using a large nationwide electronic database.

METHODS

This study was designed as a retrospective cohort study including GCA patients first diagnosed between 2002-2017 and age, sex and enrollment time-matched controls. Follow-up began at the date of first GCA-diagnosis and continued until first diagnosis of malignancy, death or end of study follow-up.

RESULTS

The study enrolled 7213 GCA patients and 32,987 age- and sex-matched controls. The mean age of GCA diagnosis was 72.3 (SD 9.9) years and 69.1% were women. During the follow-up period, 659 (9.1%) of GCA patients were diagnosed with solid malignancies and 144 (2.0%) were diagnosed with hematologic malignancies. In cox-multivariate-analysis the risk of solid- malignancies (HR = 1.12 [95%CI: 1.02-1.22]), specifically renal neoplasms (HR = 1.60 [95%CI: 1.15-2.23]) and sarcomas (HR = 2.14 [95%CI: 1.41-3.24]), and the risk of hematologic malignancies (HR = 2.02 [95%CI: 1.66-2.47]), specifically acute leukemias (HR = 1.81 [95%CI: 1.06-3.07]), chronic leukemias (HR = 1.82 [95%CI: 1.19-2.77]), Hodgkin's lymphomas (HR = 2.42 [95%CI: 1.12-5.20]), non-Hodgkin's-lymphomas (HR = 1.66: [95%CI 1.21-2.29]) and multiple myeloma(HR = 2.40 [95%CI: 1.63-3.53]) were significantly increased in GCA patients compared to controls. Older age at GCA-diagnosis (HR = 1.36 [95%CI: 1.25-1.47]), male-gender (HR = 1.46 [95%CI: 1.24-1.72]), smoking (HR = 1.25 [95%CI: 1.04-1.51]) and medium-high socioeconomic status (HR = 1.27 [95%CI: 1.07-1.50]) were independently associated with solid malignancy while age (HR = 1.47 [95%CI: 1.22-1.77]) and male-gender (HR = 1.61 [95%CI: 1.14-2.29]) alone were independently associated with hematologic- malignancies.

CONCLUSION

our study demonstrated higher incidence of hematologic and solid malignancies in GCA patients. Specifically, leukemia, lymphoma, multiple myeloma, kidney malignancies, and sarcomas. Age and male gender were independent risk factors for hematological malignancies among GCA patients, while for solid malignancies, smoking and SES were risk factors as well.

All-cause and cause-specific mortality in patients with giant cell arteritis: a nationwide, population-based cohort study

OBJECTIVES

To investigate whether giant cell arteritis (GCA) is associated with increased all-cause and cause-specific mortality.

METHODS

A nationwide, population-based cohort study in Denmark using medical and administrative registries. GCA cases were defined as patients aged ≥50 years from 1996-2018 with a first-time discharge diagnosis of GCA and ≥3 prescriptions for prednisolone within 6 months following diagnosis. Each GCA patient was matched based on age, sex and calendar time to 10 persons without a history of GCA. Index date was the date for the third prednisolone prescription. We used a pseudo-observation approach to calculate all-cause and cause-specific mortality, adjusted risk differences (RDs) and relative risks (RRs).

RESULTS

We included 9908 GCA patients and 98204 persons from the general population. The median time for GCA patients to redeem the third prednisolone prescription was 74 days (IQR: 49-106). Among GCA patients, the overall mortality was 6.4% (95% CI: 5.9-6.9) 1 year after index date and 45% (95% CI: 44-47) after 10 years. Compared to the reference cohort, adjusted RDs and RRs of deaths in the GCA cohort were 2.2% (95% CI: 1.7-2.7) and 1.49 (95% CI: 1.36-1.64) after 1 year, and 2.1% (95% CI: 1.0-3.3) and 1.03 (95% CI: 1.00-1.05) 10 years after index date. GCA patients had a higher risk of death due to infectious, endocrine, cardiovascular, and gastrointestinal diseases.

CONCLUSIONS

GCA is associated with increased all-cause mortality, particularly within the first year following the diagnosis. Cause-specific mortality indicates that mortality in GCA may in part be due to glucocorticoid-related complications.

Giant Cell Arteritis and Cardiac Comorbidity

Giant cell arteritis (GCA) is a large vessel vasculitis with a pathogenesis that involves two CD4 T-helper cell lineages, Th1 and Th17. The goal of GCA treatment is to achieve clinical remission and prevent complications, especially vision loss. Despite recent advances in treatment and diagnostic modalities for GCA, there continues to be a gap in the medical literature in addressing treatment and follow-up for patients with GCA after clinical remission is achieved. Of the most important issues to address in this patient population by rheumatologists and primary care physicians alike, is that of cardiovascular disease (CVD) risks in GCA patients associated with the vasculitis and its mainstay of treatment with high-dose glucocorticoids over a prolonged period of time. Physicians must be aware of the CVD events that have been observed in a higher proportion compared to the general population in GCA patients, including strokes, thoracic aortic aneurysms and dissections, myocardial infarctions, and peripheral vascular disease. This review will focus on the risk of CVD in GCA patients, with recommendations for management and follow-up.

Identification of Acute Giant Cell Arteritis in Real-World Data Using Administrative Claims-Based Algorithms

Objective

The objective of this study was to validate claims‐based algorithms for identifying acute giant cell arteritis (GCA) that will help generate real‐world evidence on comparative effectiveness research and epidemiologic studies. Among patients identified by the GCA algorithm, we further investigated whether GCA flares could be detected by using claims data.

Methods

We developed five claims‐based algorithms based on a combination of International Classification of Diseases, Ninth Revision (ICD‐9) diagnosis codes, specialist visits, and dispensed medications using Medicare Parts A, B, and D linked to electronic medical records (2006‐2014). Acute cases of GCA were determined by chart review using the treating physician’s diagnosis of GCA as the gold standard. Among the patients identified with acute GCA, we assessed if a GCA flare occurred during the year after initial diagnosis.

Results

The number of patients identified by each algorithm ranged from 220 to 896. Positive predictive values (PPVs) of the algorithms ranged from 60.7% to 84.8%. Requirement for disease‐specific workups, multiple diagnosis codes, or specialist visits improved the PPVs. The highest PPV (84.8%) was noted in an algorithm that required two or more diagnosis codes of GCA from inpatient, emergency department, or outpatient rheumatology visits plus a prednisone‐equivalent dose greater than or equal to 40 mg/day occurring 14 days before or after the second ICD‐9 diagnosis date, with the cumulative days’ supply greater than or equal to 14 days. Among patients identified as having GCA, 18.2% of patients had definite evidence of a flare and 25% had a potential flare.

Conclusion

A claims‐based algorithm requiring two or more ICD‐9 diagnosis codes from inpatient, emergency department, or outpatient rheumatology visits and high‐dose glucocorticoid dispensing can be a useful tool to identify acute GCA cases in large administrative claims databases.

Pathogenesis of Giant Cell Arteritis and Takayasu Arteritis-Similarities and Differences

PURPOSE OF REVIEW

Giant cell arteritis (GCA) and Takayasu arteritis (TAK) are auto-inflammatory and autoimmune diseases with a highly selective tissue tropism for medium and large arteries. In both diseases, CD4⁺ T cells and macrophages form granulomatous lesions within the arterial wall, a tissue site normally protected by immune privilege. Vascular lesions can be accompanied by an extravascular component, typically an intense hepatic acute phase response that produces well-known laboratory abnormalities, e.g., elevated ESR and CRP. It is unclear whether GCA and TAK lie on a spectrum of disease or whether they represent fundamentally different disease processes.

RECENT FINDINGS

GCA and TAK share many clinical features, but there are substantial differences in genetics, epidemiology, disease mechanisms, response to treatment, and treatment complications that give rise to different disease trajectories. A significant difference lies in the composition of the wall-infiltrating immune cell compartment, which in TAK includes a significant population of CD8⁺ T cells as well as natural killer cells, specifying disparate disease effector pathways mediating tissue damage and vessel wall remodeling. Despite the similarities in tissue tropism and histomorphology, GCA and TAK are two distinct vasculitides that rely on separate disease mechanisms and require disease-specific approaches in diagnosis and management.