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

doi:10.1016/j.semarthrit.2014.10.010

Seminars in Arthritis and Rheumatism

Volume 44, Issue 5, April 2015, Pages 586-591

https://doi.org/10.1016/j.semarthrit.2014.10.010 Get rights and content

Abstract

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 I² 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.

Introduction

The association between chronic inflammation and premature atherosclerosis is well recognized [1], [2]. Several studies have demonstrated the detrimental effect of inflammatory cytokines, oxidative stress, and activated leukocytes on endothelial function, resulting in the acceleration of atherosclerosis [3], [4], [5], [6]. Chronic inflammation has also been shown to promote the coagulation cascade, impair the anti-coagulation pathway, and inhibit fibrinolysis resulting in a hypercoagulable state [7], [8]. These factors may serve as the fundamental pathophysiology of the development of premature coronary artery disease (CAD). Moreover, an increased incidence of CAD has been observed in several chronic inflammatory disorders, such as rheumatoid arthritis, idiopathic inflammatory myopathy, systemic sclerosis, and systemic lupus erythematosus [9], [10], [11], [12].

Giant cell arteritis (GCA) is a chronic inflammatory condition characterized by medium- and large-vessel granulomatous vasculitis, typically affecting adults older than 50 years of age [13]. Vascular complications of GCA include ischemic optic neuropathy, stroke, large-vessel stenosis, and aneurysm [14]. Patients with GCA may be at an increased risk of CAD as well. However, the data on CAD risk in these patients remain unclear due to conflicting epidemiological studies [15], [16], [17]. Thus, to further investigate this association, we conducted a systematic review and meta-analysis of case–control and cohort studies that compared the risk of CAD in patients with GCA versus non-GCA participants.

Section snippets

Search strategy

Two investigators (P.U. and M.J.K.) independently searched published studies indexed in MEDLINE and EMBASE database from inception to August 2014 as well as the American College of Rheumatology annual conference abstract database from 2006 to 2013 using the search strategy described in Appendix 1. A manual search of references of selected retrieved articles was also performed.

Inclusion criteria

The inclusion criteria were as follows: (1) cohort or case–control study (either prospective or retrospective) published

Results

Our search strategy yielded 314 potentially relevant studies. Of them, 293 studies were excluded, as they were not cohort/case–control studies or were not conducted in patients with GCA. Overall, 17 studies underwent full-length article review. Eight of them were excluded since they were descriptive studies without a control group [21], [22], [23], [24], [25], [26], [27], [28] and two studies were excluded because they reported CAD mortality ratios among patients with GCA but did not report

Discussion

In contrast to other chronic systemic inflammatory diseases, an increased CAD risk among patients with GCA was not observed in this meta-analysis [9], [10], [11], [12]. There are few possible explanations for this negative result.

First, interestingly, several studies have found a lower prevalence of cardiovascular risk factors, particularly diabetes mellitus (DM) and dyslipidemia among patients with GCA compared with non-GCA controls [16], [34], [35], [36], [37], [38]. The reason why patients

Conclusion

In contrast to other rheumatic inflammatory disorders, a significant increased CAD risk among patients with GCA was not observed in this meta-analysis. The reason for this negative finding remains unclear but could possibly be related to the lower baseline cardiovascular risk and the older age at diagnosis.

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Atteintes coronariennes et artérite a cellules géantes : à propos de 2 cas et revue de la littérature
2023, Revue de Medecine Interne
Les coronarites sont une complication rare mais grave de l’artérite à cellules géantes (ACG), avec une prévalence estimée à moins de 1 %, cependant difficile à établir, et de survenue précoce dans l’histoire de la maladie.
Nous décrivons 2 cas de patients atteints d’ACG présentant une coronarite et proposons une revue de la littérature sur cette complication.
La première patiente présentait un angor stable sur une coronarite du tronc commun avec une sténose ostiale. La corticothérapie associée d’emblée à du tocilizumab a permis une amélioration. Une angioplastie a été réalisée à 6 mois avec une bonne évolution. Le second patient présentait une coronarite ostiale tritronculaire asymptomatique. La corticothérapie a permis une amélioration clinicobiologique de l’ACG. Deux ans après, il a présenté une rechute avec un syndrome coronarien aigu, d’évolution favorable après angioplastie, majoration des corticoïdes et ajout de tocilizumab.
Les patients présentés ont été traités avec succès par une corticothérapie associée à du tocilizumab, et une angioplastie de leurs sténoses coronaires. L’efficacité du tocilizumab dans l’ACG n’a pas été évaluée spécifiquement sur les coronarites du fait de la rareté de cette complication. Notre expérience et les cas rapportés dans la littérature suggèrent de bons résultats de l’angioplastie dans cette indication. Des études avec un suivi à plus long terme seront nécessaires pour évaluer notamment le risque de resténose.
Coronaritis is a rare but serious complication of giant-cell arteritis (GCA), with an estimated prevalence of less than 1%, however difficult to establish, and of early onset.
We describe 2 cases of GCA presenting with coronaritis and present a review of the literature on this complication.
The first patient presented with stable angina on common trunk coronaritis with ostial stenosis. Corticosteroid combined with tocilizumab from the outset resulted in improvement. Angioplasty was performed at 6 months with good outcome. The second patient presented with asymptomatic tritruncular ostial coronaritis. Corticosteroid allowed clinic-biological improvement of GCA. Two years later, he presented relapse with an acute coronary syndrome, with favorable evolution after angioplasty, increase of corticosteroids and addition of tocilizumab.
Patients presented were successfully treated with corticosteroids combined with tocilizumab and angioplasty of their coronary stenoses. Efficacy of tocilizumab in GCA has not been evaluated especially on coronaritis due to the rarity of this complication. Our experience and the cases reported in the literature suggest good results of angioplasty in this indication. Studies with long-term follow-up will be necessary to evaluate the risk of restenosis.
Cardiovascular Disease in Large Vessel Vasculitis: Risks, Controversies, and Management Strategies
2023, Rheumatic Disease Clinics of North America
Citation Excerpt :
In contrast, conflicting evidence exists with respect to whether the incidence of MI is greater than that which would be expected for age in GCA. Although several cohort studies suggested increased risk,24,25 a 2015 systematic review and meta-analysis identified a nonsignificant trend only toward increased coronary artery events in patients with GCA.26 Subsequently, a very large study of 9778 patients with GCA matched to nonvasculitis controls by age, sex, and number years of history, found that postdiagnosis, patients with GCA were significantly more likely to have incident MI’s, with an adjusted HR of 1.57.27
Reprint of: Giant cell arteritis: Ischemic complications
2020, Journal Europeen des Urgences et de Reanimation
Les complications ischémiques de l’artérite à cellules géantes surviennent essentiellement chez des patients présentant une vascularite encore non diagnostiquée ou mal contrôlée par le traitement.
Lorsque le traitement contrôle symptômes et signes biologiques, les complications sont généralement attribuées à l’athérosclérose.
Les complications ophtalmiques sont les plus fréquentes, dominées par la neuropathie optique ischémique antérieure aiguë.
Les accidents vasculaires cérébraux se localisent de façon privilégiée dans le territoire vertébral postérieur.
Les complications coronariennes par vascularite sont exceptionnelles.
Le diagnostic des complications ischémiques de membre bénéficie largement des progrès de l’imagerie (signe du halo à l’échographie, hypermétabolisme au TEP-scanner).
Le traitement repose sur la corticothérapie (initialement au moins 1 mg/kg d’équivalent prednisone, précédé de bolus intraveineux selon les cas), le contrôle des facteurs de risque cardiovasculaire traditionnels et la prescription d’antiagrégant plaquettaire ; l’héparinothérapie est à envisager pour les complications ischémiques des membres.
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 1 mg/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.
Giant cell arteritis: Ischemic complications
2019, Presse Medicale
Les complications ischémiques de l’artérite à cellules géantes surviennent essentiellement chez des patients présentant une vascularite encore non diagnostiquée ou mal contrôlée par le traitement.
Lorsque le traitement contrôle symptômes et signes biologiques, les complications sont généralement attribuées à l’athérosclérose.
Les complications ophtalmiques sont les plus fréquentes, dominées par la neuropathie optique ischémique antérieure aiguë.
Les accidents vasculaires cérébraux se localisent de façon privilégiée dans le territoire vertébral postérieur.
Les complications coronariennes par vascularite sont exceptionnelles.
Le diagnostic des complications ischémiques de membre bénéficie largement des progrès de l’imagerie (signe du halo à l’échographie, hypermétabolisme au TEP-scanner).
Le traitement repose sur la corticothérapie (initialement au moins 1 mg/kg d’équivalent prednisone, précédé de bolus intraveineux selon les cas), le contrôle des facteurs de risque cardiovasculaire traditionnels et la prescription d’antiagrégant plaquettaire ; l’héparinothérapie est à envisager pour les complications ischémiques des membres.
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 1 mg/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.
Vascular calcification in patients with large-vessel vasculitis compared to patients with hyperlipidemia
2019, Seminars in Arthritis and Rheumatism
Citation Excerpt :
In addition, none of our GCA patients were smokers in contrast to the HLD group, where 59% reported smoking history, underscoring the importance of traditional cardiovascular risk factors like hyperlipidemia, male sex and smoking in the development of coronary calcification [26–28]. Previous studies have shown conflicting results about whether patients with GCA are at increased risk for myocardial infarction. [29–32]. Large population-based studies found an increased risk for myocardial infarction in patients with GCA compared to age- and sex-matched controls that was greatest within the first year after GCA diagnosis [30,32].
Calcification of the coronary arteries, aorta, and branch vessels can occur in both large-vessel vasculitis (LVV) and atherosclerosis. The study objective was to determine the location and amount of vascular calcification in patients with LVV versus hyperlipidemia (HLD) and to identify risk factors associated with vascular calcification in LVV.
Patients with giant cell arteritis (GCA), Takayasu's arteritis (TAK), and HLD underwent non-contrast computed tomography of the aorta and branch vessels. Vascular calcification in 14 specific arterial territories (4 segments of the aorta, 9 branch arteries, and the coronary arteries) was quantified throughout the large arteries by a cumulative Agatston score. Multivariate linear regression analyses were used to identify associations between traditional and disease-specific risk factors and total Agatston score.
A total of 88 subjects, including GCA (n = 29); TAK (n = 22); and HLD (n = 37), participated. Prevalence of vascular calcification in the aorta and branch vessels significantly differed in the coronary arteries (HLD = 67%, GCA = 35%, TAK = 9%, p < 0.01). Total Agatston scores were higher in GCA (median 3260, range 25–18,138) versus HLD (460, 19–17,215) (p < 0.01) but did not significantly differ between GCA and TAK (1944, 52–47,520) (p = 0.53). In multivariable regression analysis, age, type of vasculitis, and prednisone use was associated with vascular calcification in LVV.
The prevalence of coronary artery calcification is lower in LVV compared to HLD, but the amount of total vascular calcification throughout the large arteries is greater in LVV. Both traditional and disease-specific risk factors are associated with vascular calcification in LVV.
Improving diagnosis and prognosis in giant cell arteritis: Still more issues than answers
2017, European Geriatric Medicine

View all citing articles on Scopus

: Authors׳ contributions: Patompong Ungprasert: study design, data search and collection, statistical analysis, and writing manuscript. Matthew J. Koster: data search and collection and revising manuscript. Kenneth J. Warrington: study design and revising manuscript.

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

Abstract

Objective

Methods

Result

Conclusion

Introduction

Section snippets

Search strategy

Inclusion criteria

Results

Discussion

Conclusion

Semin Arthritis Rheum

Lancet

Rev Med Interne

Control Clin Trial

Eur J Intern Med

Autoimmun Rev

Atherosclerosis in patients with autoimmune disorders

Arterioscler Thromb Vasc Biol

Inflammation in atherosclerosis

Nature

Common inflammatory mediators orchestrate pathophysiological processes in rheumatoid arthritis and atherosclerosis

Rheumatology (Oxford)

Interaction between oxidative stress and high-density lipoprotein cholesterol is associated with severity of coronary artery calcification in rheumatoid arthritis

Arthritis Care Res (Hoboken)

Pathogen-sensing plasmacytoid dendritic cells stimulate cytotoxic T-cell function in atherosclerotic plaque through interferon-alpha

Circulation

Endothelial dysfunction in young patients with long-term rheumatoid arthritis and low disease activity

Atherosclerosis

Inflammation, innate immunity and blood coagulation

Hamostaseologie

The interactions between inflammation and coagulation

Br J Haematol

Cardiovascular death in rheumatoid arthritis: a population-based study

Arthritis Rheum

Risk of coronary heart disease and stroke in a large British cohort of patients with systemic lupus erythematosus

Rheumatology (Oxford)

Risk of coronary artery disease in patients with systemic sclerosis: a systematic review and meta-analysis

Clin Rheumatol

Epidemiology of giant cell arteritis and polymyalgia rheumatica

Arthritis Rheum

Giant cell arteritis and cardiovascular disease in older adults

Heart