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Show Original Contribution Section Editors: Clare Fraser, MD Susan Mollan, MD Baseline Characteristics and Clinical Presentation of Biopsy-Proven Giant Cell Arteritis in White Compared with Black Patients Emily Sun, BS, Ximin Li, ScM, Anna M. Gruener, BMBS, MSc, FRCOphth, Jessica R. Chang, MD, Amanda D. Henderson, MD, Andrew R. Carey, MD Background: Giant cell arteritis (GCA) is the most prevalent systemic vasculitis in the elderly and can lead to permanent vision loss if left untreated. Most earlier studies have evaluated GCA in primarily white populations, and GCA was traditionally thought to occur at nearly negligible frequency in black populations. Our previous study showed that GCA may occur at similar rates in white and black patients, but little is known about the presentation of GCA in black patients. The purpose of this study is to examine baseline presentation of biopsy-proven GCA (BP-GCA) in a tertiary care center–based population with a sizeable proportion of black patients. Methods: Retrospective study from a single academic institution of a previously described cohort of BP-GCA. Presenting symptoms, laboratory findings, and GCA Calculator Risk score were compared in black and white patients with BP-GCA. Results: Among 85 patients with biopsy-proven GCA, 71 (84%) were white and 12 (14%) were black. White patients had higher rates of elevated platelet count (34% vs 0%, P = 0.04), whereas black patients had higher rates of diabetes mellitus (67% vs 12%, P , 0.001). There were no statistically significant differences in age, gender, biopsy classification (active vs healed arteritis), cranial symptoms, visual symptoms/ophthalmic findings, rates of abnormal erythrocyte sedimentation rate or C-reactive protein, unintentional weight loss, polymyalgia rheumatica, or GCA risk calculator score. Department of Ophthalmology (ES, ADH, ARC), Wilmer Eye Institute, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Biostatistics (XL), Biostatistics Center, Johns Hopkins School of Public Health, Baltimore, Maryland; Department of Ophthalmology (AMG), Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom; Division of Clinical Neuroscience (AMG), School of Medicine, University of Nottingham, Nottingham, United Kingdom; and Keck School of Medicine of the University of Southern California (JRC), USC Roski Eye Institute, Los Angeles, California. Supported by the P30 Core Grant (P30EY001765). The authors report no conflicts of interest. Address correspondence to Andrew R. Carey, MD, NeuroOphthalmology Division, Department of Ophthalmology, Johns Hopkins School of Medicine, Wilmer Eye Institute, 2 nd Floor, 600 N. Wolfe Street, Baltimore, MD 21287; E-mail: drcarey06@gmail.com 504 Conclusions: Presenting features of GCA were similar between white and black patients in our cohort, except for rates of abnormal platelet level and diabetes. Physicians should feel comfortable relying on the usual clinical features for the diagnosis of GCA independent of race. Journal of Neuro-Ophthalmology 2023;43:504–508 doi: 10.1097/WNO.0000000000001817 © 2023 by North American Neuro-Ophthalmology Society G iant cell arteritis (GCA), also known as temporal arteritis, is one of the most common primary inflammatory diseases in the elderly (1). It is a medical emergency that, left untreated, can lead to irreversible visual loss, making early diagnosis critical (2). Common symptoms of GCA due to inflammation of the wall of the affected vessel include headache, scalp tenderness, jaw claudication, polymyalgia rheumatica, and visual abnormalities (1). However, patients with GCA can also present with other less common symptoms, making diagnosis a challenge (3). Although there have been significant diagnostic advances over the past decade, including use of neuroimaging and color Doppler ultrasound, temporal artery biopsy (TAB) remains the primary modality for diagnosing GCA (3,4). It is traditionally believed that GCA is comparatively uncommon in black populations (1,5,6). However, this conclusion has largely been drawn from early studies of GCA that primarily evaluated white populations in Europe and North America. These studies suggested that the incidence of GCA in black patients is low, despite drawing their conclusions from relatively small sample sizes (1,5). Although there has been limited study of GCA in more diverse populations, low case numbers have limited definitive conclusions (7). Despite the scarce amount of research done in populations with a sizable number of black patients, the idea that GCA is a disease that occurs almost exclusively in white patients is widely accepted (1,5–7). Sun et al: J Neuro-Ophthalmol 2023; 43: 504-508 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution In our previous study evaluating the incidence of biopsyproven GCA (BP-GCA) over a 10-year period in Baltimore, MD, we found that GCA may occur at similar rates in white and black patients (8). For a disease like GCA, where early diagnosis is critical to prevent permanent blindness, the widely published belief that GCA is rare in black patients may result in missed diagnoses, untreated disease, and avoidable adverse outcomes that perpetuate racial inequities (9). In order to reduce racial disparities in health care, it is necessary to confront our preconceived assumptions and biases surrounding disease. There is little information on GCA in black patients to provide adequate guidance when it comes to considering and diagnosing this disease. To address this gap in the medical literature, we therefore revisited our cohort in Baltimore and conducted a follow-up study to compare the baseline characteristics and/or symptoms before diagnosis in black and white patients with BPGCA. Here, we report on the clinical presentation of GCA in a population with a sizable number of black patients. Our hope is to help physicians better identify patients with this potentially blinding condition. METHODS diagnosis, but data for this study were collected from the time of their presentation, before formal diagnosis of GCA and subsequent initiation of corticosteroid treatment. Formal diagnosis of GCA was defined as the date of the TAB. Visual manifestations that were categorized included transient monocular vision loss (TMVL, also known as amaurosis fugax), ischemic optic neuropathy (ION), central retinal artery occlusion (CRAO), and diplopia (either transient or cranial nerve palsy). Nonvisual cranial manifestations included headache, superficial temporal artery tenderness, jaw claudication, and scalp tenderness. The presence of polymyalgia rheumatica (PMR), unintentional weight loss, and diabetes mellitus was also noted. Test results included erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and platelet counts. For the few patients who were initiated on steroids before formal diagnosis of GCA, test results from the closest date within one month before steroid prescription were recorded. ESR was considered elevated if levels were above the upper limit of normal (ULN), defined as age/2 in men and (age +10)/2 in women (10). CRP was considered elevated if it was above 2.5x the ULN (11). Platelets were considered elevated if above 400,000 (400 K) per microliter. Giant Cell Arteritis Risk Calculator Study Design and Population We performed a retrospective review of patients found to have BP-GCA in our previous study (8). The study was approved by the Institutional Review Board of the Johns Hopkins School of Medicine, which waived the need for informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. The study population was made up of the 92 BP-GCA patients included in our previous report (8). To briefly review, these patients were referred for TAB from within the Wilmer Eye Institute and other departments of the Johns Hopkins Health System, including all satellite sites. Patients were considered to have BP-GCA if histologic examination of the temporal artery revealed arteritis. Patients with biopsies of healed arteritis were counted as having BP-GCA, whereas indeterminate findings of biopsies were counted as negative. Patients who never received corticosteroids or were on treatment for less than a month and monitored without recurrence were deemed not to have GCA and hence excluded from this study. The same racial and ethnic labels were used in this study as in our prior study (8), with patients being categorized by their self-identified race and/or ethnicity labels located in the electronic medical record system and the US Census. Clinical Data Elements Demographic information, clinical presentation, medical history, and laboratory test results were extracted from medical charts. All included patients had a BP-GCA Sun et al: J Neuro-Ophthalmol 2023; 43: 504-508 Ing et al (12) recently developed and validated neural network and logistic regression diagnostic prediction models for patients with suspected GCA. Of note, 15 patients from this cohort were used as part of their model (14 white, 1 black), which overall included 1,201 patients. According to the model, patients with a 7.5% observed probability cutoff point have a low risk of GCA, with statistical sensitivity of 99%. The collected baseline symptoms for each patient were entered into the online calculator (https://goo.gl/ THCnuU) to calculate the risk of GCA. It was noted whether patients had a mean risk of 7.5% or greater. Statistical Analysis Demographic baseline characteristics including clinical presentation, medical history, test results, and calculated GCA risk were summarized and compared between the races. Mean and SD were summarized for continuous variables, and t test was used for comparison. Frequency and percentage were calculated for categorical variables, and Chi-square test was used for comparison. A significance level of 0.05 was used. All analyses were performed in R (The R Foundation for Statistical Computing, Institute for Statistics and Mathematics, Vienna, Austria). RESULTS Of the 92 BP-GCA patients from the previous study, 5 patients were excluded due to clinical disagreement of GCA and 2 patients due to data from relapse rather than initial diagnosis, leaving 85 patients for analysis, including 71 505 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution white (84%) and 12 black (14%) patients, as well as 2 (2%) of unknown or other race. Sixty-one (72%) were women. The mean age of patients at the time of diagnosis was 76 years (range, 53–94 years). Forty percent of patients presented with unintentional weight loss, and 38% had PMR. The baseline demographics are presented in Table 1. At presentation, 56% had at least one visual manifestation, including TMVL (26%), ION (31%), CRAO (5%), and diplopia (24%). Eighty-eight percent of patients had at least one nonvisual cranial manifestation, including headache (78%), superficial temporal artery tenderness (34%), jaw claudication (50%), and scalp tenderness (36%). The baseline manifestations are presented in Table 2. Laboratory results showed a median ESR of 70 mm/ hour and a median platelet count of 347 thousand per microliter. Eighty-five percent of patients had an elevated ESR, 72% had an elevated CRP, and 29% had an elevated platelet count. Using the GCA risk calculator, the mean risk was 50% using the neural network and 42% using the logistic regression model. Ninety-three percent of patients had a risk of 7.5% or greater in at least the neural or logistic regression model (sensitivity 99%). Results and risk scores are presented in Table 3. Racial Differences White patients had higher rates of elevated platelet count (34% vs 0%, P = 0.04), whereas black patients had higher rates of diabetes mellitus (67% vs 11%, P , 0.001). There was no statistically significant difference in age, sex, biopsy classification, or presence of any cranial or visual manifestations between white and black patients. Laboratory results other than platelet count (i.e., ESR, CRP) were similar. Unintentional weight loss and PMR occurred at similar frequencies between the 2 groups. There was no difference in GCA risk calculator score (logistic regression and neural network) or GCA risk calculator score above 7.5% (sensitivity 99%). CONCLUSIONS Although our previous study demonstrated that GCA occurs at similar rates in black and white patients, GCA has commonly been thought to disproportionately affect white populations (7,13). As such, there are limited data on the incidence, clinical presentation, and treatment outcomes of GCA in black populations, which may perpetuate health care inequities. Therefore, it is crucial to examine the presentation of disease in diverse populations. Comparing the baseline characteristics of GCA in black and white patients allows us to question and challenge any preexisting assumptions surrounding race and disease. An understanding of the clinical presentation of GCA in diverse populations is important for accurate and prompt diagnosis and treatment. The current results indicate that black patients with GCA have similar baseline characteristics and clinical presentations compared with white patients, with the exception of rates of abnormal platelet levels and diabetes. We found that there were minimal differences in baseline characteristics between black and white patients. Our findings are consistent with other published data mostly consisting of small case series (14,15). Our study is one of the first to examine the presentation of GCA in a population with a relatively high percentage of black patients, namely, 12 black patients out of 87 patients over a 10-year period. To our knowledge, the only other North American study of GCA with a comparable sample size that examined baseline characteristics between white and black patients was a multicenter retrospective cohort study by Garrity et al. (16), which examined 32 black patients over a 20-year period compared with 84 white patients from a previously published study out of Iowa. Our current cohort represents a new data set evaluating these features. There are some key differences between our cohort and theirs: Garrity et al only included information from patients in neuro-ophthalmic practice, whereas our cohort was collected from consecutive TABs in a tertiary academic center rather than using a historical control. The overall findings of Garrity et al that the 2 groups have similar presentation are confirmed in our study. In addition, our study provides new information: because our cohort includes patients with nonophthalmic presentations, we offer more generalizable data regarding GCA patients. The study of Garrity et al also identified an increased rate of headache in African Americans compared with Caucasians, although the TABLE 1. Baseline demographics and key findings of patients with BP-GCA, overall and separated by race n (%) Age (median, IQR) Female (%) Unintentional weight loss (%) Polymyalgia (%) Diabetes mellitus (%) Healed (vs active) arteritis Overall Black White P 85 76 (53, 94) 59/83 (71) 32/81 (40) 31/81 (38) 16/80 (20) 16/83 (19) 12 (14%) 72 (61, 92) 10/12 (83) 5/12 (42) 3/12 (25) 8/12 (67) 5/12 (42) 71 (84%) 77 (53, 94) 49/71 (69) 27/69 (39) 28/69 (41) 8/68 (12) 11/71 (15) 0.7 0.5 1 0.5 ,0.001* 0.08 * = P , 0.05. BP-GCA, biopsy-proven giant cell arteritis; IQR, interquartile range. 506 Sun et al: J Neuro-Ophthalmol 2023; 43: 504-508 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution TABLE 2. Presenting cranial and visual manifestations of patients with BP-GCA, overall and separated by race Headache (%) Superficial temporal artery tenderness or reduced pulse (%) Jaw claudication (%) Scalp tenderness (%) No nonvisual cranial manifestations (%) Transient monocular vision loss (%) Ischemic optic neuropathy (%) Central retinal artery occlusion (%) Diplopia (%) No visual manifestations (%) Overall Black White P 64/82 (78) 28/82 (34) 41/82 (50) 29/81 (36) 10/83 (12) 21/81 (26) 25/81 (31) 4/80 (5) 19/81 (23) 36/81 (44) 9/12 (75) 5/12 (42) 6/12 (50) 5/12 (42) 1/12 (8) 2/12 (17) 3/12 (25) 1/12 (8) 3/12 (25) 5/12 (42) 55/70 (79) 23/70 (33) 35/70 (50) 24/69 (35) 9/71 (13) 19/69 (28) 22/69 (32) 3/68 (4) 16/69 (23) 31/69 (45) 1 0.8 1 0.9 1 0.7 0.9 1 1 1 BP-GCA, biopsy-proven giant cell arteritis. rate of headache was surprisingly low among Caucasians in their study (75% vs 45%, P , 0.01); however, we found no significant difference (75% in black vs 79% vs whites). They also found a higher incidence of jaw claudication in Caucasians (54% vs 31%, P = 0.03), whereas we did not (50% vs 51%). Garrity et al also reported higher rates of acute vision loss in Caucasians from their historical Iowa-based control group than in African Americans (98% vs 78%, P , 0.001), whereas we again found no difference (36% vs 33%). These differences may be due to different inclusion criteria. Our cohort also offers information on patients presenting without ocular manifestation, which has not been previously reported among black patients with GCA. We found a higher percentage of white patients had elevated platelet counts at baseline. Although there have been reports of racial differences in platelet levels, the literature is inconsistent. Some studies have reported that black patients have lower platelet counts than white patients (17), whereas others suggest the opposite (18,19). In this study, our finding that white patients are more likely to have elevated platelet levels could be significant for diagnosing GCA. A systematic review has confirmed elevated platelet count of .400K is predictive of a positive TAB, increases risk of mortality, and is incorporated into the GCA risk calculator (12,20). Importantly, based on our findings, clinicians should keep in mind that black patients with GCA may be less likely to present with elevated platelet counts. Our article is the first to evaluate the utility of the GCA risk calculator in a minority population. As race was not a factor examined in the development and validation of the multivariable prediction model for suspected GCA, whether the GCA risk calculator would be equally useful in black vs white patients remains currently unknown. We found no significant difference between black and white patients in their calculated mean probability score. This suggests that this tool may be equally useful in independently predicting the risk of GCA before TAB in both black and white patients. This, in turn, may not only aid clinicians in the diagnosis of GCA in black patients but also decrease the need for TAB in low-score at-risk subjects. Because the GCA risk calculator does not rely on race as a parameter, its use by physicians may help reduce any racial inequities in the diagnosis of GCA. As it appears to be equally useful in both black and white patients, the GCA risk calculator can provide physicians a systematic way to evaluate the risk of GCA in all patients, preventing physicians from unknowingly using race as a heuristic when making a diagnosis. This study was limited by its retrospective design and was thus subject to the observational and selection biases typically associated with retrospective studies. Information on all TABLE 3. Presenting laboratory findings and composite risk score of patients with BP-GCA, overall and separated by race High ESR (%) High CRP (2.5x ULN) (%) High platelet count (400 K/mL) (%) Normal ESR, CRP, & platelets (%) GCA risk score LR (mean [SD]) GCA risk score NN (mean [SD]) GCA risk score .7.5% (99% sensitivity) (%) Overall Black White P 64/75 (85) 48/67 (72) 21/73 (29) 15/83 (18) 42 (25) 50 (24) 71/76 (93) 11/12 (92) 6/12 (50) 0/12 (0) 1/12 (8) 35 (22) 44 (25) 11/12 (92) 53/63 (84) 42/55 (76) 21/61 (34) 14/71 (20) 43 (25) 51 (24) 60/64 (94) 0.8 0.1 0.04* 0.6 0.3 0.4 1 * = P , 0.05. BP-GCA, biopsy-proven giant cell arteritis; CRP, C-reactive protein; ESR, estimated sedation rate; GCA, giant cell arteritis; LR, logistic regression; NN, neural network. Sun et al: J Neuro-Ophthalmol 2023; 43: 504-508 507 Copyright © North American Neuro-Ophthalmology Society. Unauthorized reproduction of this article is prohibited. Original Contribution baseline symptoms were not reliably available for all patients in the sample, and data were thus limited to what the clinician evaluated as part of routine care. In addition, as patients were from a single hospital center, data may not be generalizable to other populations. Furthermore, because this study was performed in the United States, our black and white populations may be genetically distinct from black and white populations in other countries. We also did not reexamine biopsy specimens, but instead relied on the pathologist’s initial diagnosis. However, doing so is also more representative of “real-world” data and the typical clinical experience. Furthermore, we did not assess preoperative corticosteroid use and any effects this may have had on biopsy or laboratory results. However, we did ensure that laboratory results were taken before any corticosteroid use whenever possible. Future research is still needed to investigate racial differences and their impact on treatment outcomes, risk of relapse during steroid taper, and risk of complications from treatment. The results of this study have many implications for the diagnosis and treatment of GCA. Our overall finding that GCA presents similarly in both black and white patients may seem obvious to some because there is no evidence to suggest that race would influence the clinical presentation in black patients. Yet, although race should not affect clinical care, studies have shown that there are still notable differences in clinical practice and medical decision making with patients of different racial groups (9). Therefore, it is crucial for researchers and physicians to routinely question beliefs surrounding disease in relation to race. GCA is not a disease that affects only white populations as previously assumed. Our findings serve as an important reminder to physicians that GCA presents similarly in black and white patients. The data from this retrospective cohort study show that black and white patients with BP-GCA present with similar baseline characteristics. However, clinicians need to be mindful that black patients with GCA may have lower platelet levels than white patients. Because black patients have a comparatively higher predisposition for diabetes (21), clinicians may also want to consider introducing steroid-sparing agents earlier. STATEMENT OF AUTHORSHIP Conception and design: E. Sun, A. R. Carey; Acquisition of data: E. Sun, A. R. Carey; Analysis and interpretation of data: E. Sun, X. Li, A. M. Gruener, J. R. Chang, A. D. Henderson, A. R. Carey. Drafting the manuscript: E. Sun; Revising the manuscript for intellectual content: E. Sun, X. Li, A. M. Gruener, J. R. Chang, A. D. Henderson, A. R. Carey. Final approval of the completed manuscript: E. Sun, X. Li, A. M. Gruener, J. R. 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