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Giant Cell Arteritis-A Report on Systematic Physical Evaluation and Large Vessel Involvement as a Prognostic Risk Factor for Complicated Disease Course, Real Life Data.

Nazanin Naderi

Background: Large vessel involvement (LVI) as a prognostic factor regarding flare frequency and glucocorticoid (GC) demand has not been investigated in giant cell arteritis (GCA). LVI may indicate a complicated disease course but periodic imaging is not an accepted norm for reevaluation and data on findings of vascular damage with clinical vascular assessment is scarce.

Objectives: This study was conducted to explore periodic peripheral vascular evaluation as a tool for a) detecting smouldering disease, b) identifying LVI, and c) to investigate whether LVI predicts frequent flares on high dose GC.

Methods: A portion of all consecutive newly diagnosed patients with GCA and polymyalgia rheumatica, referrals for second opinion or initiation of GC-sparing drug in patients with these diagnoses between July 2011 and May 2015 were evaluated and followed on regular intervals by one rheumatologist. Only those with GCA were included. Patients were evaluated at follow-ups with auscultation of the heart and peripheral vessels, palpation of the peripheral pulses and pressure measurement of the brachial and dorsal pedal arteries. Imaging was done if: new vascular bruit or pressure asymmetry, frequent flares, long standing disease or rise in inflammatory markers without any other explanation.

Results: Imaging revealed LVI in 58% (LV-GCA). Sixty-five percent developed pressure asymmetry, 65% of them had LVI. With pressure measurements 73% of those with LV-GCA could be found. Six patients exhibited a relapsing and remitting course of pressure asymmetries. Thirty-one percent of the ankle pressure asymmetries (APA) at baseline were due to vasculitis. APA occurred significantly higher in LV-GCA patients (p=0.0017). Sixty-five percent of the patients had flares on high dose GC, 76% of them had LVI (p=0.014).

Conclusions: Periodic vascular assessment is reliable to I) use as an independent activity marker, II) evaluate treatment efficacy, III) detect LVI and smouldering inflammation. LVI predicts a complicated disease course.