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• IMPLEMENTATION OF THE RECENT ACR/EULAR CLASSIFICATION CRITERIA FOR GIANT CELL ARTERITIS: IS “CLASSIFICATION WITH CLINICAL CRITERIA ONLY” ADEQUATE FOR ALL?
  Burak Ince, Murat İnanç
  Published on: 2 February 2023

• Published on: 2 February 2023

  IMPLEMENTATION OF THE RECENT ACR/EULAR CLASSIFICATION CRITERIA FOR GIANT CELL ARTERITIS: IS “CLASSIFICATION WITH CLINICAL CRITERIA ONLY” ADEQUATE FOR ALL?

  • Burak Ince, Rheumatologist Başakşehir Çam ve Sakura City Hospital, Istanbul
  • Other Contributors:
    • Murat İnanç, Rheumatologist

  We read the article “2022 American College of Rheumatology/EULAR Classification Criteria for Giant Cell Arteritis" by Ponte et al. with great interest (1). There was a long-standing need for revision of classification criteria for giant cell arteritis (GCA) due to the insufficient sensitivity of the ACR 1990 criteria in recent studies (2). This could be explained by enrolment of patients with different clinical phenotypes to the cohorts depending on the improvement in the imaging methods in addition to clinician’s assessment over the years. Especially, implementation of cross-sectional imaging including FDG – PET improved the diagnosis of GCA and facilitated the recognition of disease patterns without cranial manifestations. Patients with isolated extra-cranial involvement were reported to have a diagnostic delay up to 5 months compared to classical GCA patients and late recognition of large vessel involvement could cause permanent organ damage (3). Thoracic aorta dilatation / aneurysm has been reported in 15% and large artery stenosis in 30% in patients with proven aortic inflammation (4). The ACR 1990 Criteria were not sufficient to identify this subgroup and patients who participate in clinical trials evaluating the efficacy of further treatment options. The new criteria were expected to fill this gap.

  We implemented new criteria to our single reference center cohort with long-term follow-up consisted of 89 patients with a median follow-up time of 4 years T...

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  We read the article “2022 American College of Rheumatology/EULAR Classification Criteria for Giant Cell Arteritis" by Ponte et al. with great interest (1). There was a long-standing need for revision of classification criteria for giant cell arteritis (GCA) due to the insufficient sensitivity of the ACR 1990 criteria in recent studies (2). This could be explained by enrolment of patients with different clinical phenotypes to the cohorts depending on the improvement in the imaging methods in addition to clinician’s assessment over the years. Especially, implementation of cross-sectional imaging including FDG – PET improved the diagnosis of GCA and facilitated the recognition of disease patterns without cranial manifestations. Patients with isolated extra-cranial involvement were reported to have a diagnostic delay up to 5 months compared to classical GCA patients and late recognition of large vessel involvement could cause permanent organ damage (3). Thoracic aorta dilatation / aneurysm has been reported in 15% and large artery stenosis in 30% in patients with proven aortic inflammation (4). The ACR 1990 Criteria were not sufficient to identify this subgroup and patients who participate in clinical trials evaluating the efficacy of further treatment options. The new criteria were expected to fill this gap.

  We implemented new criteria to our single reference center cohort with long-term follow-up consisted of 89 patients with a median follow-up time of 4 years The sensitivity of 75.3% ACR 1990 Criteria was 75.3% and the sensitivity of ACR 2022 Criteria was found to be 82% (5). Of the patients without apparent cranial manifestations in our cohort (n=19) only 20% and 35% met the 1990 and 2022 criteria, respectively. Since all our patients met at least one laboratory, biopsy or imaging criteria, this rate could be lower in cohorts which includes patients with normal laboratory values and/or negative imaging.

  On the other hand, the presence of only subjective clinical criteria such as morning stiffness, headache and scalp tenderness, negative predictive value of new criteria may be lower than expected. In our cohort, 40 (45%) patients had ≥3 clinical criteria (only 8 of them had sudden vision loss) and met the classification criteria without the need for positive laboratory, biopsy, or imaging. Although specificity of the criteria with and without biopsy is around 95% in the study performed by experts of the disease in the present study, we suggest that mandatory requirement of a single objective criterion (e.g., high CRP, histopathology, imaging) in addition to clinical criteria except vision loss may improve specificity especially in less experienced centers.

  1. Ponte C, Grayson PC, Robson JC, et al. 2022 American College of Rheumatology/EULAR classification criteria for giant cell arteritis. Annals of the Rheumatic Diseases. 2022;81,12:1647.
  2. Seeliger B, Sznajd J, Robson JC, et al. Are the 1990 American College of Rheumatology vasculitis classification criteria still valid? Rheumatology (Oxford). 2017;56,7:1154-1161.
  3. Tomelleri A, Campochiaro C, Sartorelli S, et al. Presenting features and outcomes of cranial-limited and large-vessel giant cell arteritis: a retrospective cohort study. Scand J Rheumatol. 2022;51,1:59-66.
  4. de Boysson H, Liozon E, Espitia O, et al. Different patterns and specific outcomes of large-vessel involvements in giant cell arteritis. J Autoimmun. 2019;103:102283.
  5. Ince B, Artan S, Yalcinkaya Y, et al. Long-term follow-up of 89 patients with giant cell arteritis: a retrospective observational study on disease characteristics, flares and organ damage. Rheumatol Int. 2021;41,2:439-448.

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  Conflict of Interest:
  None declared.

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