Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Association between Vascular Physical Examination Findings and Angiographically-Detected Arterial Lesions in Subjects with Large Vessel Vasculitis.

Grayson4,  Peter C., Tomasson3,  Gunnar, Cuthbertson11,  David, Carette9,  Simon, Hoffman6,  Gary S., Khalidi10,  Nader A., Langford5,  Carol A.

Boston University, Boston, MA
University of Hamilton, Hamilton, ON, Canada
University of South Florida
Boston University School of Medicine, West Newton, MA
Boston University School of Medicine, Boston, MA
Boston University School of Medicine
Cleveland Clinic Foundation, Cleveland, OH
Cleveland Clinic Foundation, Pepper Pike, OH
Johns Hopkins Bayview Medical Center, Baltimore, MD
Mayo Clinic, Rochester, MN
Toronto Western Hospital, Toronto, ON, Canada

Purpose:

The vascular physical examination (PE) to assess for pulses, bruits, and systolic blood pressure (SBP) readings is considered essential in the clinical evaluation of patients with large vessel vasculitis (LVV), including Takaysu's arteritis (TAK) and giant cell arteritis (GCA). This study examined the relationship between findings on PE and angiographic-detected arterial lesions in subjects with established LVV.

Methods:

100 subjects (TAK=68, GCA=32) enrolled in a longitudinal, observational cohort underwent standardized PE and magnetic resonance angiography of the aorta and its primary branches. Analysis was restricted to bilateral common carotid, subclavian, and axillary arteries. Sensitivity and specificity was calculated for the association between PE findings (absent pulse, bruit, and inter-arm SBP difference) and angiographic lesions defined as stenosis, occlusion, or aneurysm. To determine if PE findings accurately localized arterial lesions, a PE finding (e.g. left carotid bruit) was compared to angiogram findings in both the anatomically correlated vessel (e.g. left carotid artery) and in all vessels within the region (carotid or subclavian or axillary arteries).

Results:

Participants were predominantly female (92%), Caucasian (87%), and had mean ages of 40 years (TAK) and 69 years (GCA). 67% had at least one PE abnormality: absent pulse (41%-TAK, 38%-GCA), bruit (54%-TAK, 28%-GCA), or >= 15 mmHg SBP difference (52%-TAK, 29%-GCA). Lesions in any of the carotid, subclavian, or axillary arteries were detected in 75% of subjects (82%-TAK, 59%-GCA). Individual PE findings had poor sensitivity (range 14–51%) and good-excellent specificity (range 72–98%) to detect arterial lesions. Sensitivity improved (range 52–71%) and specificity worsened (range 59–86%) if any of the 3 different PE maneuvers considered in combination were abnormal. Sensitivity worsened (range 6–30%) and specificity improved (range 88–100%) if 2 or more of the PE findings were abnormal or if individual PE findings were compared to regional vessels without imposing single vessel anatomic correlation.

Physical Exam FindingAngiogram Comparison VesselNo.SensitivitySpecificity
Individual Exam Findings with Anatomic Correlated
Absent Pulse
Common CarotidIpsi CC1791498
RadialIpsi SA1934094
Bruit
Common CarotidIpsi CC/SA195799
Common CarotidIspi CC1794582
SubclavianIspi S1912791
Blood Pressure
BP DifferenceBilat SA965172
Any 1 Abnormal Exam Finding
Carotid Bruit No Carotid PulseIpsi CC1795280
Subclavian Bruit No Radial PulseIpsi SA1955486
Subclavian Bruit BP DifferenceIpsi SA1956559
No Radial Pulse BP DifferenceIpsi SA1956361
Subclavian Bruit BP Difference No Radial PulseIpsi SA1957159
Absent Pulse
Common CarotidIpsi CC/SA195799
Common CarotidBilat CC/SA1967100
Bruit
Common CarotidIpsi CC/SA1943088
Common CarotidBilat CC/SA1952791
SubclavianIpsi CC/SA1953091
SubclavianBilat CC/SA1962998
2 or More Combined Abnormal Exam Findings
Carotid Bruit No Carotid PulseIpsi CC1797100
Subclavian Bruit No Radial PulseIpsi SA1951498
Subclavian Bruit BP DifferenceIpsi SA1951493
No Radial Pulse BP DifferenceIpsi SA1952595
Subclavian Bruit BP Difference No Radial PulseIpsi SA195699
Key: Ispi=Ispilateral, Bilat=Bilateral, CC=Common Carotid, SA=Subclavian/Axillary, S=Subclavian

Conclusion:

In subjects with established LVV, vascular PE findings have low sensitivity but high specificity to detect arterial disease. Abnormal PE findings are highly associated with the presence of arterial lesions, but normal PE findings do not rule out the possibility of arterial disease. Even when considering PE findings in combination, sensitivity is still inadequate to rule out arterial lesions. Specificity improves when PE findings are evaluated in association with a broader region of arterial lesions rather than a specific anatomically correlated vessel, suggesting that PE findings do not always accurately localize disease. While valuable in the assessment of arterial disease in LVV, the PE should not form the sole basis of assessment and should be supplemented by angiography.

To cite this abstract, please use the following information:
Grayson, Peter C., Tomasson, Gunnar, Cuthbertson, David, Carette, Simon, Hoffman, Gary S., Khalidi, Nader A., et al; Association between Vascular Physical Examination Findings and Angiographically-Detected Arterial Lesions in Subjects with Large Vessel Vasculitis. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :2198
DOI: 10.1002/art.29962

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