POS0271 CLINICAL SYMPTOMS AT GIANT CELL ARTERITIS DIAGNOSIS AS PREDICTORS OF PERMANENT VISUAL LOSS

Background

Giant cell arteritis (GCA) is the most prevalent vasculitis in the elder. Nearly 20% of patients experience transient or permanent visual loss (PVL). It has been reported that erythrocyte sedimentation rate (ESR), haemoglobin (Hb), constitutional syndrome (CS) and fever are prognostic factors that predict PVL but models have shown poor diagnostic performance.

Objectives

To evaluate if clinical signs, symptoms and blood tests can predict PVL at GCA diagnosis.

Methods

We retrospectively included patients from the Spanish Vasculitis Registry (REVAS) from 2005 to 2009. Clinical and blood tests data were obtained from medical records. We randomly split the cohort using shrinkage function to create a derivation and a validation cohort. In the derivation set we compared data and we built a multivariable logistic regression model to predict PVL. Internal validity was evaluated with 1000 bootstrap. External validity was evaluated using the validation set of data. Performance of the model was determined using the area under the curve (AUC) with 95% confidence interval. Calculations were done using StataBE 17.0.

Results

We included 620 patients (derivation cohort: 397 patients). Clinical signs, symptoms and blood tests results according to the presence or absence of PVL (Table 1). Mean age at diagnosis was 76.3 years and PVL was present in 86 (21.7%) patients. Significant predictors at baseline were age (p=0.000), hypertension (p=0.04), fever (p=0.001), jaw claudication (0.000), transient visual loss (TVL, p=0.000) and decreased temporal artery (TA) pulse (p=0.004). Multivariable logistic regression showed that age older than 75 years (OR 2.7, p=0.000), jaw claudication (OR, 2.75; p=0.000) and TVL (OR 7.2, p=0.000) were risk factors for PVL. CS was the only protective factor (OR 0.57, p=0.017). Hypertension (OR 1.4, IC95%: 0.88 – 2.3) and diabetes (OR 1.63, IC95%: 0.94 – 2.8) were not statistically significant. Our model showed an AUC 0.8 (IC 95%: 0.75 – 0.84). A 1000 bootstrap analysis showed good internal validity (AUC 0.79, IC95%: 0.74 – 0.83). Validation cohort comprised 223 patients and the AUC of the model in this dataset showed an AUC 0.81. We compared our model to previously published models and we found that our model had a higher AUC (AUC 0.8, IC 95%: 0.75-0.84 vs. AUC 0.65, IC95%: 0.6 – 0.7; p < 0.0001).

Table 1.

Baseline date according to the presence or absence of permanent visual loss.

Permanent Visual LossNo Permanent Visual LossVariableMean/ProportionSDMean/ProportionSDSignificanceFemale69.8%72.0%0.68Age >75 y.o.72.1%53.4%0.000Hypertension64.3%51.6%0.04Diabetes25.9%16.9%0.06Fever18.6%36.8%0.001Constitutional syndrome42.4%53.2%0.075Polymyalgia40.7%39.7%0.87Headache79.1%79.2%0.987Jaw claudication68.2%39.7%0.000Tenderness of the TA38.6%31.4%0.22Transient visual loss39.0%10.5%0.000Stroke3.5%3.9%0.86Transient ischaemic attack0.0%4.2%0.053Decreased TA pulse66.7%48.0%0.004TA enlargement55.1%50.9%0.51Haemoglobin11.11.211.41.40.37Erythrocyte sedimentation rate95.026.296.426.80.67C Reactive protein9.76.210.48.60.8

SD: Standard deviation. TA: Temporal artery.

Conclusion

Age > 75 years, jaw claudication and TVL can predict PVL, being the CS a protective factor for this complication. Blood test data are not good PVL predictive factors.

References

[1]Nesher G. J Autoimm. 2014;48-49:73-75.

[2]Cid MC et al. Arthritis Rheum. 1998;41:26-32.

Acknowledgements

on behalf of the Spanish Resgistry of Systemic Vascuitis (REVAS)

Disclosure of Interests

None declared

Comparison of the Birmingham Vasculitis Activity Score and the Five-Factor Score to Assess Survival in Antineutrophil Cytoplasmic Antibody-Associated Vasculitis: A Study of 550 Patients From Spain (REVAS Registry)

OBJECTIVE

To compare the accuracy of the Birmingham Vasculitis Activity Score (BVAS), version 3, and the Five Factor Score (FFS), version 1996 and version 2009, to assess survival in antineutrophil cytoplasmic antibody-associated vasculitis (AAV).

METHODS

A total of 550 patients with AAV (41.1% with granulomatosis with polyangiitis, 37.3% with microscopic polyangiitis, and 21.6% with eosinophilic granulomatosis with polyangiitis), diagnosed between 1990 and 2016, were analyzed. Receiver operating characteristic (ROC) curves and multivariable Cox analysis were used to assess the relationships between the outcome and the different scores.

RESULTS

Overall mortality was 33.1%. The mean ± SD BVAS at diagnosis was 17.96 ± 7.82 and was significantly higher in nonsurvivors than in survivors (mean ± SD 20.0 ± 8.14 versus 16.95 ± 7.47, respectively; P < 0.001). The mean ± SD 1996 FFS and 2009 FFS were 0.81 ± 0.94 and 1.47 ± 1.16, respectively, and were significantly higher in nonsurvivors than in survivors (mean ± SD 1996 FFS 1.17 ± 1.07 versus 0.63 ± 0.81 [P < 0.001] and 2009 FFS 2.13 ± 1.09 versus 1.15 ± 1.05 [P < 0.001], respectively). Mortality rates increased according to the different 1996 FFS and 2009 FFS categories. In multivariate analysis, BVAS, 1996 FFS, and 2009 FFS were significantly related to death (P = 0.007, P = 0.020, P < 0.001, respectively), but the stronger predictor was the 2009 FFS (hazard ratio 2.9 [95% confidence interval 2.4-3.6]). When the accuracy of BVAS, 1996 FFS, and 2009 FFS to predict survival was compared in the global cohort, ROC analysis yielded area under the curve values of 0.60, 0.65, and 0.74, respectively, indicating that 2009 FFS had the best performance. Similar results were obtained when comparing these scores in patients diagnosed before and after 2001 and when assessing the 1-year, 5-year, and long-term mortality. Correlation among BVAS and 1996 FFS was modest (r = 0.49; P < 0.001) but higher than between BVAS and the 2009 FFS (r = 0.28; P < 0.001).

CONCLUSION

BVAS and FFS are useful to predict survival in AAV, but the 2009 FFS has the best prognostic accuracy at any point of the disease course.

Clinical characteristics and outcome of Spanish patients with ANCA-associated vasculitides: Impact of the vasculitis type, ANCA specificity, and treatment on mortality and morbidity

The aim of this study was to describe the clinical characteristics of ANCA-associated vasculitides (AAV) at presentation, in a wide cohort of Spanish patients, and to analyze the impact of the vasculitis type, ANCA specificity, prognostic factors, and treatments administered at diagnosis, in the outcome.A total of 450 patients diagnosed between January 1990 and January 2014 in 20 Hospitals from Spain were included. Altogether, 40.9% had granulomatosis with polyangiitis (GPA), 37.1% microscopic polyangiitis (MPA), and 22% eosinophilic granulomatosis with polyangiitis (EGPA). The mean age at diagnosis was 55.6 ± 17.3 years, patients with MPA being significantly older (P < 0.001). Fever, arthralgia, weight loss, respiratory, and ear-nose-throat (ENT) symptoms, were the most common at disease onset. ANCAs tested positive in 86.4% of cases: 36.2% C-ANCA-PR3 and 50.2% P-ANCA-MPO. P-ANCA-MPO was significantly associated with an increased risk for renal disease (OR 2.6, P < 0.001) and alveolar hemorrhage (OR 2, P = 0.010), while C-ANCA-PR3 was significantly associated with an increased risk for ENT (OR 3.4, P < 0.001) and ocular involvement (OR 2.3, P = 0.002). All patients received corticosteroids (CS) and 74.9% cyclophosphamide (CYC). The median follow-up was 82 months (IQR 100.4). Over this period 39.9% of patients suffered bacterial infections and 14.6% opportunistic infections, both being most prevalent in patients with high-cumulated doses of CYC and CS (P < 0.001). Relapses were recorded in 36.4% of cases with a mean rate of 2.5 ± 2.3, and were more frequent in patients with C-ANCA-PR3 (P = 0.012). The initial disease severity was significantly associated with mortality but not with the occurrence of relapses. One hundred twenty-nine (28.7%) patients (74 MPA, 41 GPA, 14 EGPA) died. The mean survival was 58 months (IQR 105) and was significantly lower for patients with MPA (P < 0.001). Factors independently related to death were renal involvement (P = 0.010), cardiac failure (P = 0.029) and age over 65 years old (P < 0.001) at disease onset, and bacterial infections (P < 0.001). An improved outcome with significant decrease in mortality and treatment-related morbidity was observed in patients diagnosed after 2000, and was related to the implementation of less toxic regimens adapted to the disease activity and stage, and a drastic reduction in the cumulated CYC and CS dose.