[Incidence of cardiovascular events in giant cell arteritis: preliminary results of a prospective double cohort study (GRACG)]

An Updated Review of Cardiovascular Events in Giant Cell Arteritis

Giant cell arteritis (GCA) is a systemic vasculitis with a direct and indirect increased risk of acute and chronic vascular events, affecting large and medium vessels, and responsible for most of the morbidity and mortality of this disease. We aimed in this review to provide an updated synthesis of knowledge regarding cardiovascular events observed in GCA. By definition, GCA patients are over 50 and often over 70 years old, and subsequently also present age-related cardiovascular risk factors. In addition, the systemic and vascular inflammation as well as glucocorticoids (GC) probably contribute to an accelerated atherosclerosis and to vascular changes leading to arterial stenoses and aortic dilations and/or dissections. GCA-related ischemic complications, especially ophthalmologic events, stroke or myocardial infarcts are mostly observed within the first months after the diagnosis, being mainly linked to the vasculitic process. Conversely, aortic complications, including dilations or dissections, generally occur several months or years after the diagnosis, mainly in patients with large-vessel vasculitis. In these patients, other factors such as atherosclerosis, GC-related endothelial damage and vascular wall remodeling/healing probably contribute to the vascular events. GCA management includes the detection and treatment of these previous and newly induced cardiovascular risk factors. Hence, the use of cardiovascular treatments (e.g., aspirin, anticoagulation, statins, anti-hypertensive treatments) should be evaluated individually. Aortic structural changes require regular morphologic evaluations, especially in patients with previous aortitis. The initial or secondary addition of immunosuppressants, especially tocilizumab, an anti-IL-6 receptor antibody, is discussed in patients with GCA-related cardiovascular complications and, more consensually, to limit GC-mediated comorbidities.

Myocardial infarction during giant cell arteritis: A cohort study

BACKGROUND

Cardiovascular risk is increased in giant cell arteritis (GCA). We aimed to characterize myocardial infarction (MI) in a GCA cohort, and to compare the GCA and non-GCA population affected by MI.

METHODS

In patients with a biopsy-proven diagnosis of GCA between 1 January 2001 and 31 December 2016 in Côte D'Or (France), we identified patients with MI by crossing data from the territorial myocardial infarction registry (Observatoire des Infarctus de Côte d'Or) database. Five controls (non-GCA + MI) were paired with one case (GCA + MI) after matching for age, sex, cardiovascular risk factors and prior cardiovascular disease. MI were characterized as type 1 MI (T1MI), resulting from thrombus formation due to atherothrombotic disease, or type 2 MI (T2MI), due to a myocardial supply/demand mismatch. GCA-related MI was defined as MI occurring within 3 months of a GCA flare (before or after).

RESULTS

Among 251 biopsy-proven GCA patients, 13 MI cases were identified and paired with 65 controls. MI was GCA-related in 6/13 cases, accounting for 2.4% (6/251) of our cohort. T2MI was more frequently GCA-related than GCA-unrelated (80% vs. 16.7%, p = 0.080), and GCA diagnosis was the only identified triggering factor in 75% of GCA-related T2MI. GCA-unrelated MI were more frequently T1MI and occurred in patients who had received a higher cumulative dose of prednisone (p = 0.032). GCA was not associated with poorer one-year survival.

CONCLUSIONS

GCA-related MI are mainly T2MI probably caused by systemic inflammation rather than coronaritis. GCA-unrelated MI are predominantly T1MI associated with atherothrombotic coronary artery disease.

[Giant cell arteritis: Ischemic complications]

GCA ischemic complications occur generally in patients with a yet undiagnosed or uncontrolled disease. When disease control is fair, ischemic complications may be due mostly to atheromatosis. Ophtalmic complications are most frequent and are dominated by anterior ischemic optic neuropathy. Vasculitic strokes occur essentially in the vertebrobasilar arterial territory. Overt vasculitic coronary disease is exceptional. The diagnosis of upper and lower limbs ischemic complications benefit from advances in echography (halo sign) and positron emission tomography imaging. Treatment relies on corticosteroids (initially 1mg/kg prednisone or more, preceded by intravenous methylprednisolone gigadoses if necessary), the control of cardiovascular risk factors and antiplatelet drugs; heparin may be indicated for threatening limbs ischemia.

Adverse Events in Giant Cell Arteritis and Rheumatoid Arthritis Patient Populations: Analyses of Tocilizumab Clinical Trials and Claims Data

INTRODUCTION

The safety profile of tocilizumab (TCZ) in patients with rheumatoid arthritis (RA) is well established. TCZ was approved to treat giant cell arteritis (GCA) in 2017 in the USA and Europe, and its safety profile in patients with GCA continues to be defined. The objective of this analysis was to examine incidence rates (IRs) of adverse events of special interest (AESI) occurring during the TCZ clinical development program and in healthcare claims data in patients with GCA or RA.

METHODS

TCZ-naïve patients with GCA or RA were identified in the MarketScan administrative healthcare claims database. TCZ-treated patients with GCA from the GiACTA trial and TCZ-treated patients with RA from pooled clinical trial data were analyzed. The IRs of AESI (AESI IRs) were calculated for all cohorts. In the claims cohorts, risks of AESI were estimated using Poisson regression.

RESULTS

TCZ-naïve claims cohorts comprised 4804 patients with GCA [mean (standard deviation) age 73.4 (9.8) years; follow-up 3.9 (3.1) years] and 15,164 patients with RA [age 60.3 (8.2) years; follow-up, 4.5 (2.8) years]. TCZ-treated clinical trial cohorts comprised 149 patients with GCA [age 69.5 (8.4) years; exposure approx. 138 patient-years (PY)] and 7647 with RA [age 52 (12.6) years; exposure approx. 22,394 PY]. The IRs of infections, stroke, malignancies, myocardial infarction, and gastrointestinal perforations in the GCA claims cohort exceeded those in the RA claims cohort; the risk of AESI (adjusted for age and glucocorticoid use) was higher in patients with GCA than in those with RA. Similar patterns to the claims cohorts in terms of the AESI IRs were observed in clinical trial cohorts, although the number of events was limited in the GCA trial cohort.

CONCLUSION

Higher IRs of AESI were observed in patients with GCA versus those with RA in both TCZ-naïve and -treated cohorts. Differences in underlying disease, age, and glucocorticoid use may influence AESI incidence, irrespective of intervention.

FUNDING

This study was funded by F. Hoffmann-La Roche Ltd and Genentech, Inc. Article processing charges were funded by F. Hoffmann-La Roche Ltd. Plain language summary is available for this article.

Smoking as a risk factor for giant cell arteritis: A systematic review and meta-analysis

OBJECTIVES

To investigate the association between smoking and giant cell arteritis (GCA).

METHODS

A systematic review was performed and meta-analysis conducted on observational studies that reported absolute numbers and/or statistical comparisons with 95% confidence intervals comparing smoking history and presence of GCA, among patients with GCA and non-GCA controls. Studies were reviewed in accordance with PRISMA guidelines. Point estimates and standard errors were extracted from individual studies and were combined by the generic inverse variance method of DerSimonian and Laird. A random-effects meta-analysis was performed. Statistical heterogeneity was assessed using the Cochran's Q test which was complemented with the I² statistic.

RESULTS

The initial search yielded 3312 articles. Of these, thirteen studies (8 prospective and, 5 retrospective case-control studies) with unique cohorts were identified and included in the primary analysis (ever vs. never smoking history). Patients in the GCA cohort were more likely to have a history of smoking with an odds ratio of 1.19 (95% CI, 1.01-1.39). Considerable heterogeneity was present (I²= 85%). Five of these studies included information on current smoking status. One additional study, which only reported current smoking status, was also included. The GCA cohort showed an association with current smoking with an odds ratio of 1.18 (95% CI, 1.01-1.38).

CONCLUSION

Our study demonstrated a statistically significant increased risk of GCA among both current and ever smokers compared to non-smokers.

Predictors of Cardiovascular Hospitalization in Giant Cell Arteritis: Effect of Statin Exposure. A French Population-based Study

Objective.

To identify predictors and protectors for cardiovascular hospitalization in a giant cell arteritis (GCA) population-based cohort.

Methods.

Using the French National Health Insurance system, we included patients with incident GCA from the Midi-Pyrenees region, southern France, from January 2005 to December 2008 and randomly selected 6 controls matched by sex and age at calendar date. We used a Cox model to identify independent predictors for cardiovascular hospitalization [combining stroke, coronary artery disease (CAD), heart failure, peripheral arterial disease, or cardiac arrhythmias].

Results.

Among 103 patients with GCA followed 48.9 ± 14.8 months, the incidence rates of hospitalization for cardiovascular disease, atherosclerotic disease (combining stroke, CAD, and peripheral arterial disease), heart failure, and cardiac arrhythmias were 48.6, 17.5, 14.8, and 9.8 events per 1000 person-years versus 14.9, 4.6, 6.2, and 2.5 events per 1000 person-years among controls, respectively. In patients with GCA, cardiovascular comorbidities at diagnosis (HR 6.2, 2.0–19.2), age over 77 years (HR 5.0, 1.40–17.54), as well as the cumulative defined daily dose of statins (HR 0.993, 0.986–0.999) were independent predictors for subsequent cardiovascular hospitalization. None of the 25 patients with GCA who were taking platelet aggregation inhibitors experienced a cardiovascular hospitalization during followup.

Conclusion.

Patients with GCA present a high risk of cardiovascular hospitalization after diagnosis. In patients with incident GCA from the Midi-Pyrenees region, southern France, statin therapy was associated with reduced cardiovascular hospitalizations.

Cerebrovascular accident in patients with giant cell arteritis: A systematic review and meta-analysis of cohort studies

OBJECTIVES

To investigate the risk of cerebrovascular accident (CVA) among patients with giant cell arteritis (GCA).

METHODS

We conducted a systematic review and meta-analysis of cohort studies that reported relative risks, hazard ratios, or standardized incidence ratios comparing CVA risk in patients with GCA versus non-GCA comparators. Pooled risk ratio and 95% confidence interval were calculated using a random-effect, generic inverse variance method of DerSimonian and Laird.

RESULTS

Eight studies with 17,919 patients with GCA were identified and included in our data analysis. The pooled risk ratio of CVA in patients with GCA versus non-GCA controls was 1.40 (95% CI: 1.27-1.56). The statistical heterogeneity was low with an I² of 31%.

CONCLUSIONS

Our study indicates a significantly increased risk of CVA among patients with GCA.

Lower body mass index is associated with a higher risk of giant cell arteritis: a systematic review and meta-analysis

OBJECTIVE

To characterize the possible association between body mass index (BMI) and risk of giant cell arteritis (GCA).

METHODS

We conducted a systematic review of observational studies (case-control or cohort study) that (I) reported BMI of patients with GCA prior to the diagnosis of GCA compared with subjects without GCA and (II) provided relative risk (RR), odds ratio (OR) or hazard ratio (HR) with 95% confidence interval (CI) from its regression analysis. Meta-analysis of the included studies was then performed to estimate the pooled effect using generic variance method of DerSimonian and Laird.

RESULTS

Three studies encompassing 141 patients with GCA and 85,736 controls met our eligibility criteria and were included in the data analyses. We demonstrated a statistically significant inverse relationship between BMI and risk of subsequent development of GCA as the risk increased by 8% when BMI was reduced by 1.0 kg/m(2) (pooled OR of 0.92/kg/m(2); 95% CI, 0.88-0.96).

CONCLUSIONS

Our study demonstrated a statistically significant inverse relationship between BMI and risk of subsequent development GCA. The pathophysiologic link behind this negative correlation is not well-characterized and further investigation is required.

Patients with giant cell arteritis have a lower prevalence of diabetes mellitus: A systematic review and meta-analysis

OBJECTIVE

The aim of this study is to compare the prevalence of diabetes mellitus (DM) in patients who are recently diagnosed with giant cell arteritis (GCA) with age- and sex-matched controls.

METHODS

We conducted a systematic review and meta-analysis of observational studies that (1) consisted of GCA cohort and non-GCA cohort that was randomly selected from the same population and (2) provided prevalences of DM at the time of diagnosis for patients with GCA and at the index date for controls. Pooled odds ratios and 95% confidence intervals (CIs) were calculated using a random-effect, Mantel-Haenszel analysis.

RESULTS

Five studies with 903 patients with GCA and 1064 controls were identified and included in our data analysis. We demonstrated a statistically significant lower prevalence of DM among patients with GCA with the pooled OR of 0.74 (95% CI, 0.57-0.97).

CONCLUSION

At diagnosis, patients with GCA had a lower prevalence of DM. Whether DM could be a protective factor against the development of GCA needs further investigations.

Peripheral arterial disease in patients with giant cell arteritis: a meta-analysis

AIM

To investigate the association between giant cell arteritis (GCA) and risk of peripheral arterial disease (PAD).

METHODS

We conducted a systematic review and meta-analysis of observational cohort studies that reported relative risks, hazard ratios or standardized incidence ratios with 95% confidence comparing PAD risk in patients with GCA versus non-GCA subjects. Pooled risk ratios and 95% confidence intervals were calculated using a random-effect, generic inverse variance of DerSimonian and Laird.

RESULTS

Four studies with 9789 patients with GCA and 236 728 controls were identified and included in our data analysis. The pooled risk ratio of PAD among patients with GCA compared with controls was 1.88 (95% CI 1.04-3.41). The statistical heterogeneity was high with an I(2) of 89%.

CONCLUSION

Our study demonstrated a statistically significant increased risk of PAD among patients with GCA.

Cardiovascular risk and acute coronary syndrome in giant cell arteritis: a population-based retrospective cohort study

OBJECTIVE

To assess the occurrence of acute coronary syndrome (ACS) in patients with giant cell arteritis (GCA) compared to subjects without GCA.

METHODS

We retrospectively reviewed a population-based incidence cohort of Olmsted County, Minnesota residents with GCA diagnosed in 1950-2009. We compared this cohort with a cohort of patients without GCA of similar age, sex, and calendar year from the same population.

RESULTS

The study included 245 patients with GCA and 245 non-GCA subjects. The mean ± SD Framingham cardiovascular risk score was 30% ± 19% in GCA patients and 34% ± 23% in non-GCA subjects (P = 0.096) at the incidence/index date. Diabetes mellitus was significantly less common in GCA patients than non-GCA subjects at the index date. The mean high-density lipoprotein was higher and triglycerides were lower, with fewer patients taking lipid-lowering medications in the GCA cohort compared to the non-GCA cohort at the index date. During followup, no difference between the 2 cohorts was noted in the overall rate of ACS events (hazard ratio 0.74, 95% confidence interval 0.44-1.26). Overall thrombosis in myocardial infarction scores were similar in both cohorts. Revascularization procedures were done less frequently in GCA than in non-GCA subjects (19% versus 50%; P = 0.015). Post-ACS hospital length of stays and complications were similar in both cohorts.

CONCLUSION

Multiple cardiovascular risk factors are less atherogenic at incidence of GCA. There is no overall increased risk of ACS in patients with GCA.

Is statin exposure associated with occurrence or better outcome in giant cell arteritis? Results from a French population-based study

OBJECTIVE

To investigate the potential association between statin use and giant cell arteritis (GCA) course.

METHODS

Using the French National Health Insurance system, we included patients with incident GCA from the Midi-Pyrenees region, southern France, from January 2005 to December 2008 and randomly selected 6 controls matched by age, sex, and date of diagnosis. Statin exposure was compared between patients with GCA and their controls before GCA occurrence with a logistic regression. Influence of statin exposure on prednisone requirements during GCA course was explored with a Cox model, considering statin exposure as a time-varying variable.

RESULTS

The cohort included 103 patients (80 women, mean age 74.8 ± 9 yrs, mean followup 48.9 ± 14.8 mos), compared to 606 controls. Statin exposure (27.2% of patients with GCA and 23.4% of controls) was not associated with GCA occurrence (adjusted OR 1.2, 95% CI 0.76-1.96; p = 0.41). Diabetes mellitus was significantly associated to GCA occurrence (adjusted OR 0.38, 95% CI 0.11-0.72; p = 0.008). After diagnosis, exposure to statins up to 20 months was associated with maintenance while taking low prednisone doses (p = 0.01).

CONCLUSION

Statin exposure was not associated with GCA occurrence in the general population. However, exposure to statins up to 20 months may favor a quicker corticosteroid tapering. Based on those results, statin effect on GCA course should not be definitively ruled out.

Coronary artery disease in giant cell arteritis: a systematic review and meta-analysis

OBJECTIVE

To investigate the association between giant cell arteritis (GCA) and risk of coronary artery disease (CAD).

METHODS

We conducted a systematic review and meta-analysis of observational studies that reported relative risks, hazard ratios, or standardized incidence ratios with 95% confidence interval comparing CAD risk in patients with GCA versus non-GCA controls. Pooled risk ratios and 95% confidence intervals were calculated using a random-effect, generic inverse variance of DerSimonian and Laird.

RESULT

Six studies with 10,868 patients with GCA and 245,323 controls were identified and included in our data analysis. The pooled risk ratio of CAD in patients with GCA was 1.51 and did not achieve statistical significance (95% CI: 0.88-2.61). The statistical heterogeneity was high with an I(2) of 97%.

CONCLUSION

In contrast to other chronic systemic inflammatory disorders, our meta-analysis did not show any statistically significant increased risk of CAD among patients with GCA.

Polymyalgia rheumatica and giant cell arteritis in older patients: diagnosis and pharmacological management

Giant cell arteritis (GCA) is an inflammatory vasculopathy that involves large- and medium-sized arteries and can cause vision loss, stroke and aneurysms. GCA occurs in people aged >50 years and is more common in women. A higher incidence of the disease is observed in populations from Northern European countries. Polymyalgia rheumatica (PMR) is a periarticular inflammatory process manifesting as pain and stiffness in the neck, shoulders and pelvic girdle. PMR shares the same pattern of age and sex distribution as GCA. The pathophysiology of PMR and GCA is not completely understood, but the two conditions may be related and often occur concurrently. A delay in the diagnosis should be avoided because of the risk of vascular ischaemic complications due to GCA. The diagnosis should be considered in patients aged >50 years presenting with symptoms such as new headache, visual disturbances, jaw claudication or symptoms of PMR. GCA can also present as a systemic inflammatory syndrome with fever of unknown origin. Marked elevation of acute-phase reactants, recognizable in higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels, is often seen in both PMR and GCA. However, some patients can present with a normal ESR. Confirmation of the diagnosis of GCA by temporal artery biopsy is important because clinical findings and laboratory tests are not specific, and because a diagnosis of GCA commits patients to long-term treatment with corticosteroids. The role of imaging techniques for the diagnosis of GCA remains unclear, but these modalities can be helpful in assessing the extent of vascular involvement, especially when extra-cranial disease is present. In PMR, subdeltoid and subacromial bursitis can be identified by imaging techniques, especially ultrasound or MRI. The clinical manifestations of GCA and PMR respond dramatically within 12-48 hours of starting corticosteroid treatment. The initial corticosteroid dosage commonly used in GCA is oral prednisone 40-60 mg/day, and for patients with PMR a dosage of 15-20 mg/day is often sufficient. A prolonged course of treatment is necessary, and corticosteroids are gradually tapered, guided by regular clinical evaluation and ESR (and/or CRP) measurement. Methotrexate is the best studied corticosteroid-sparing agent in GCA, and may be useful for patients with frequent disease relapses and/or corticosteroid-related toxicity. Retrospective studies favour aspirin (acetylsalicylic acid) as an effective adjuvant treatment for reducing the ischaemic complications of GCA. The long-term course of corticosteroid therapy frequently exposes elderly patients with PMR/GCA to various adverse effects, which can be attenuated with appropriate prophylactic measures. Co-morbid diseases and polypharmacy can pose particular challenges in the geriatric population. In general, the life expectancy of patients with GCA does not appear to be shortened, whereas the morbidity associated with the disease and its treatment is well recognized.

Polymyalgia rheumatica and giant cell arteritis: management of two diseases of the elderly

Both polymyalgia rheumatica (PMR) and giant cell arteritis (GCA) present with a broad spectrum of clinical manifestations and almost exclusively occur in the population aged over 50 years. After rheumatoid arthritis, PMR is the second most common autoimmune rheumatic disorder. Visual loss is the most feared complication in temporal arteritis, and extracranial arteries and/or aorta are more often involved in GCA than previously estimated. No specific laboratory parameter exists for diagnosis of PMR. Imaging techniques such as ultrasonography, MRI or 18F-fluorodeoxyglucose PET may be helpful in the diagnosis and evaluation of the extent of vascular involvement in these diseases. This article highlights upcoming new classification criteria for PMR, recent advances of diagnostic and therapeutic procedures as well as ongoing research on biomarkers and corticosteroid-sparing medications, which should improve management of PMR and GCA.

Antiplatelet therapy for the prevention of arterial ischemic events in takayasu arteritis

BACKGROUND

Vessel wall inflammation, atherosclerosis and hypercoagulability may be responsible for ischemic events in Takayasu arteritis (TA). No study has evaluated the effect of antiplatelet therapy for the prevention of ischemic events in TA.

METHODS AND RESULTS

Forty-eight patients who met the ACR Classification Criteria for TA under follow-up at the Vasculitis Unit of Universidade Federal de São Paulo were evaluated retrospectively for clinical manifestations, therapy and arterial ischemic events. The mean age at study was 38.0 years and the mean age at TA diagnosis was 29.1 years. Women comprised for 89.6% of patients and 60.4% were Caucasian. Risk factors for cardiovascular disease were found in 44 patients (91.7%) The most common comorbidities for TA patients were hypertension (77.1%), high low-density lipoprotein (45.8%) and obesity (16.7%). Antiplatelet therapy was used by 62.5% of patients whereas anticoagulants were used by 12.5%. Acute ischemic events occurred in 29.2% of patients. TA patients with ischemic events used significantly less antiplatelet agents (14.3%) than those without ischemic events (82.4%), P<0.0001. No difference concerning ischemic events was observed in patients on anticoagulant therapy (P=0.339). The 3 deaths of TA patients were observed only in those who had presented ischemic events (P=0.021). Antiplatelet agents had a protective effect against ischemic events (hazard ratio =0.055, 95% confidence interval: 0.06-0.514; P=0.011).

CONCLUSIONS

Antiplatelet therapy is associated with a lower frequency of ischemic events in patients with TA.

Proposal to decrease the number of negative temporal artery biopsies

OBJECTIVE

The percentage of negative temporal artery biopsies (TABs) remains very high in patients with suspected giant cell arteritis (GCA). The aim of our study was to identify the clinical predictors of TAB results to improve the effectiveness of this diagnostic procedure.

METHODS

We performed a cross-sectional study of 125 consecutive patients who underwent TAB in the Department of Internal Medicine of a public tertiary hospital, from January 1997 to March 2002. We compared patients with a positive and a negative biopsy result.

RESULTS

Forty-six of the 125 biopsies (36.8%) were positive for GCA and 79 (63.2%) negative. Temporal artery (TA) thickening (8.01), decreased pulse (5.58), jaw claudication (4.87), and scalp tenderness (4.29) presented the highest positive likelihood ratios (LR+). Erythrocyte sedimentation rate (ESR) (0.11), headache (0.39), TA thickening (0.42), and decreased pulse (0.48) had the lowest negative likelihood ratios (LR-). Only TA abnormalities [odds ratio (OR) 12.3] and scalp tenderness (OR 6) were independent predictors of biopsy results. By excluding patients with no evidence of TA abnormalities, scalp tenderness, or jaw claudication, only 48% of the 125 biopsies would have been performed; 59 negative biopsies would have been prevented, but six positive biopsies would have been missed.

CONCLUSION

Careful assessment of patients with clinically suspected GCA to rule out artery abnormalities, scalp tenderness, and jaw claudication can lead to a dramatic decrease in the percentage of negative biopsies. This observation may contribute to improving the physician's decision-making process when contemplating TAB.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.