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Association between strong inflammatory response and low risk of developing visual loss and other cranial ischemic
1Hospital Clínic, Barcelona, Spain.
Insights
Giant cell arteritis patients with a strong inflammatory response have a low risk of ischemic events. Conversely, those with a low inflammatory response and transient ischemic symptoms face a high risk, requiring prompt intervention.
Area of Science:
- Rheumatology
- Vascular Medicine
- Internal Medicine
Background:
- Giant cell arteritis (GCA) is a vasculitis affecting large arteries, primarily the aorta and its branches.
- Cranial ischemic events are serious complications of GCA, necessitating accurate risk stratification.
- Identifying predictive parameters for ischemic events is crucial for tailoring patient management.
Purpose of the Study:
- To identify clinical and biochemical markers that predict the risk of cranial ischemic events in patients with biopsy-proven GCA.
- To stratify GCA patients into high-risk and low-risk groups for ischemic complications.
Main Methods:
- Retrospective analysis of 200 consecutive patients with biopsy-proven GCA from three university hospitals.
- Review of clinical and biochemical data to identify parameters associated with ischemic events.
Main Results:
- Thirty-two patients developed irreversible cranial ischemic complications.
- Patients with ischemic events less frequently presented with fever and weight loss, but more frequently with amaurosis fugax and transient diplopia.
- Lower erythrocyte sedimentation rates (ESR) and higher hemoglobin and albumin levels were observed in patients with ischemic events.
- A combined low clinical and biologic inflammatory response identified patients at high risk (OR 5).
- A strong clinical or biologic inflammatory response significantly reduced the risk of ischemic events.
Conclusions:
- A robust acute-phase response (clinical and biologic) identifies GCA patients at very low risk of cranial ischemic complications.
- Patients exhibiting a low inflammatory response, especially with transient ischemic symptoms, are at high risk and require urgent therapeutic intervention.
- These findings support the potential for less aggressive treatment strategies in low-risk GCA patients.
Objective:
To identify clinical and biochemical parameters that have good predictive value for identifying giant cell (temporal) arteritis (GCA) patients who are at high or low risk of developing cranial ischemic events.
Methods:
In this multicenter study, records of patients at 3 university hospitals in Barcelona were reviewed retrospectively. Two hundred consecutive patients with biopsy-proven GCA were studied.
Results:
Thirty-two patients developed irreversible cranial ischemic complications. The duration of clinical symptoms before diagnosis was similar in patients with and those without ischemic events. Patients with ischemic complications less frequently had fever (18.8% versus 56.9%) and weight loss (21.9% versus 62%) and more frequently had amaurosis fugax (32.3% versus 6%) and transient diplopia (15.6% versus 3.6%). Patients with ischemic events had lower erythrocyte sedimentation rates (ESR) (82.7 mm/hour versus 104.4 mm/hour) and higher concentrations of hemoglobin (12.2 gm/dl versus 10.9 gm/dl) and albumin (37.4 gm/liter versus 32.7 gm/liter). Clinical inflammatory status and biologic inflammatory status were defined empirically (clinical: fever and weight loss; biologic: ESR > or =85 mm/hour and hemoglobin < 11.0 gm/dl). Patients not showing a clinical and biologic inflammatory response were at high risk of developing ischemic events (odds ratio [OR] 5, 95% confidence interval [95% CI] 2.05-12.2). The risk was greatly reduced among patients with either a clinical (OR 0.177, 95% CI 0.052-0.605) or a biologic (OR 0.226, 95% CI 0.076-0.675) inflammatory reaction. No patient with both a clinical and a biologic response developed ischemic events.
Conclusion:
The presence of a strong acute-phase response defines a subgroup of patients at very low risk of developing cranial ischemic complications. Our findings provide a rationale for testing less aggressive treatment schedules in these individuals. Conversely, a low inflammatory response and the presence of transient cranial ischemic events provide a high risk of developing irreversible ischemic complications and require a prompt therapeutic intervention.