Background According to some clinicians the course of rheumatoid arthritis (RA) has changed in the last decades. However, systemic vasculitis (SV) remains one of the most important complications of RA.
Objectives The aim of this study was to verify this clinical impression, the “changing face of RA”, characterized by SV.
Methods At the National Institute of Rheumatology 11,162 patients died between 1969 and 2000; among them 237 with RA and all of them were autopsied. This non-selected autopsy population of 237 was studied. In 53 (22.36%) of 237 patients RA was complicated by SV. RA was confirmed clinically according to the criteria of the ACR. The presence of SV was determined histologically. The “severity” of vasculitis was evaluated by semi-quantitative, visual estimation on a 0 to 3 plus scale (1). The average incidence of SV was calculated in percentage of the number of RA patients, who died in four periods of time (8-8-8-8 years) covering 32 years (between 1969 and 2000).
Results During these four periods of time (from 1969 to 2000) the average age of the RA patients with SV continuously increased somewhat (from 57.00 to 68.00 years). In the fourth period RA started later (52.00 versus 49.20 years) and its duration was longer (14.25 versus12.60 years) (Table 1).
The average incidence of SV continuously increased (from 10.77% to 34.0%) between 1969 and 2000. This was due to the fourfold raised incidence of mild SV, while the proportion of cases with severe SV only doubled (from 3.08% to 6.00%).
Conclusions The later onset of RA indicates the changing face of RA. The longer disease duration and the later death of the patients may be due to therapy. The longer life span (longer duration of the immune processes) with repeated exacerbations of vasculitis may contribute to the increased prevalence of SV at death, but the protracted disease duration (less than one and a half years) does not explain alone a threefold rise of incidence of SV. The increased incidence of SV (including fourfold for mild, and double for severe cases) in 32 years supports the changing face of RA. According to our data RA became more frequent and more aggressive at the end of the last century. The rate of cases with mild and severe vasculitis shifted; the proportion of mild cases increased fourfold in contrast with the double increment of the severe ones. This shift may be explained by the introduction of more effective therapy of RA. Introduction of more effective biological therapy may explain the actual clinical impression of a moderate course of RA in more recent years. But it cannot be excluded that some patients with severe vasculitis die before hospitalization.
Bély M, Apáthy Άgnes. Clinical Pathology of rheumatoid arthritis: Cause of death, lethal complications and associated diseases in rheumatoid arthritis. First English edition, 1-440 pp. Akadémiai Kiadό, Budapest 2012 http://www.akkrt.hu
Disclosure of Interest None declared