Aortic Aneurysm and Dissection in Giant Cell Arteritis

IN RESPONSE:

Aortic involvement in giant cell arteritis was first reported in 1937 [1]. Until recently, however, it was generally not believed to be a common occurrence. We hope that increased awareness of the association between giant cell arteritis and aortic aneurysms may reduce the morbidity and associated expense, in both economic and personal terms, of such complications.

In view of the concerns raised by Dr. Ginsburg and others and the striking association between giant cell arteritis and aortic aneurysms that we have described, we feel that patients with giant cell arteritis should be monitored for aortic disease. To date, no studies have determined the utility or the economic cost–benefit ratio of screening for aortic aneurysms in patients with this disease. Yet, because giant cell arteritis is associated with this potentially fatal complication [1], we may feel compelled to look for it. Overall, however, the entire cohort of our patients with giant cell arteritis had better than expected survival compared with age- and sex-matched controls, and most did not develop aneurysms. Until we better understand the benefits of screening for aortic aneurysms in these very elderly patients, many of whom can expect significant illness or death related to aneurysm repair, we should be cautious in our approach. We want to avoid using scarce resources on screening, particularly given the expense of procedures such as ultrasonography and computed tomography. Instead, common sense should prevail.

We certainly agree with Dr. Ginsburg that the aorta should be periodically examined in patients with giant cell arteritis, even when related clinical symptoms are absent. For patients with a history of giant cell arteritis, we currently do an annual complete physical examination that includes cardiac and carotid artery auscultation and palpation of peripheral pulses and the abdominal aorta. We also regularly obtain a chest radiograph with a lateral view if the patient has not had one in the preceding year. Although the clinical utility of such screening is not yet known, most of these patients are elderly and have other comorbid conditions for which they are regularly seen by physicians. Most have a complete annual physical examination and a chest radiograph as part of their ongoing care. Therefore, we rarely do additional studies or examinations on these patients simply to screen for aortic disease. Nevertheless, in view of the striking association between giant cell arteritis and aortic aneurysms, we believe that close follow-up is important.

• Copyright ©2004 by the American College of Physicians