Abstract
Background: Color Duplex sonography (CDS) of temporal arteries and large vessels (LV) is a recently validated diagnostic methodology for Giant Cell Arteritis (GCA). CDS combined with a fast-track approach (FTA) has improved the early diagnosis of the disease.Objectives: To assess FTA effects on the prevention of permanent visual loss (PVL), relapse and late complications of GCA compared to conventional practice. To assess the impact of COVID-19 pandemic on outcomes of GCA patients assessed with FTA.Methods: GCA patients diagnosed up to June 2020 at the Rheumatology Department, University of Pavia, were included. FTA was implemented since October 2016. FTA consists in the referral within 1 working day of a suspected GCA case to an expert rheumatologist who performs clinical evaluation and CDS.Results: One hundred sixty patients were recruited [female 120 (75%), mean age 72.4 ± 8.2 years]. Sixty-three (39.4%) evaluated with FTA, 97 (60.6%) with conventional approach. FTA patients were older (75.1 ± 7.6 vs. 70.6 ± 8.2 years old; p < 0.001). Median follow-up duration was shorter in the FTA group compared to the conventional one (0.9 vs. 5.0 years; p < 0.001). There was no difference between the two cohorts regarding major vessel district involvement (LV-GCA 17.5% vs. 22.7%; p = 0.4). PVL occurred in 8 (12.7%) FTA patients and 26 (26.8%) conventional ones (p = 0.03). The relative risk of blindness in the conventional group was 2.11 (95% C.I. 1.02–4.36; P = 0.04) as compared to FTA. Median symptom latency of patients experiencing PVL was higher in the conventional group (23 days IQR 12–96 vs. 7 days IQR 4–10, p = 0.02). During COVID-19 there was a significant increase in the occurrence of PVL (40%) including bilateral blindness despite a regularly operating FTA clinic. Cumulative incidence of relapses and time to first relapse did not change after FTA introduction (P = 0.2). No difference in late complications (stenosis/aneurysms) was detected.Conclusions: FTA including CDS evaluation contributed to a substantial reduction of PVL in GCA by shortening the time to diagnosis and treatment initiation. Relapse rate did not change upon FTA introduction, highlighting the need for better disease activity monitoring and treatment strategies optimization based on risk stratification that would predict the occurrence of relapse during glucocorticoid de-escalation.
Highlights
METHODSGiant Cell Arteritis (GCA) is the most prevalent primary systemic vasculitis [1]
The effectiveness of the fast-track approach (FTA) approach has been further highlighted in our cohort by the significant increase in diagnostic delay and occurrence of permanent visual loss (PVL), including bilateral blindness, observed during the COVID19 pandemic due to the patients’, and possibly care givers’ fear of seeking medical attention and attending the hospital
The implementation of Color Duplex sonography (CDS) into FTA clinics allowing for a prompt and direct assessment and interpretation of imaging findings by the treating physician has led to the demonstration that very early diagnosis with the aid of CDS can significantly reduce the risk of PVL in patients with GCA [6, 17]
Summary
Giant Cell Arteritis (GCA) is the most prevalent primary systemic vasculitis [1]. Permanent visual loss (PVL), one of the most feared complications of GCA, results from damage to ophthalmic, retinal or ciliary arteries [3]. The heavy morbidity burden of GCA is due to its rather late onset (usually occurring over the age of 50 years old) and the occurrence of PVL in approximately 20% patients, usually at the very beginning of the disease. The clinical spectrum of GCA comprises large vessel complications such as thoracic and abdominal aortic aneurysm or dissection, which can increase the risk of mortality [2, 4]. Color Duplex sonography (CDS) of temporal arteries and large vessels (LV) is a recently validated diagnostic methodology for Giant Cell Arteritis (GCA). CDS combined with a fast-track approach (FTA) has improved the early diagnosis of the disease
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