Background Giant cell arteritis (GCA) is the most common large vessel vasculitis seen in the elderly. Rapid referral to secondary care is recommended in the UK and EULAR guidelines to confirm the diagnosis, organise temporal artery biopsy (TAB) and start treatment with corticosteroids to prevent complications such as blindness, but it can be difficult to ensure this happens.
Objectives We have set up a secondary care acute referral pathway for GCA in North Bristol Trust, UK and we review the cases from our first fifteen months.
Methods A rapid access pathway for the referral of suspected GCA from primary care or acute medicine was set up, aiming for all patients to be seen within 72 hours, either in a “Hot Clinic” held weekly, or on the Day Case Unit, with prompt access to TAB within one week. We collected clinical and laboratory data on all patients referred in the first seventeen months (August 2011- October 2012) including the pre-biopsy clinical impression, time to biopsy and the final diagnosis.
Results 54 patients (mean age 67) were referred from a local population of approximately 500,000, 20% of whom are aged over 65. 32% of patients were seen within 24 hours, 58% within 72 hours, and 10% (where the diagnosis was thought unlikely, and/or a phone consultation was carried out first) waited for longer than one week. All patients had headache. Our clinical assessment before biopsy was that GCA was the likely diagnosis in 21 cases, but not in the other 33 patients. Of those, 22 were not referred for biopsy because an alternative diagnosis was made, and/or GCA was felt extremely unlikely. A TAB was therefore done in 35 patients (21 cases where GCA was thought likely and in 14 other cases where no reasonable alternative diagnosis was found on clinical assessment). 12 were positive including one in whom the clinical impression was thought unlikely to be GCA. Biopsies were carried out within 1 week in 33%. 2 biopsy positive patients had normal systemic inflammatory markers at first presentation. Four patients had a palpable thickened temporal artery at presentation and in three of these cases the biopsy was positive. 13 were already taking oral steroids for at least 3 days by the time of biopsy, of whom 6 had a positive biopsy. Biopsy positive patients had a mean age of 76. Viscosity at presentation ranged from 1.49-2.59 (mean 1.90)
Conclusions It is feasible to set up a rapid access pathway for GCA diagnosis and management, and most referrals were appropriate, but after a detailed history and examination, more than half were felt to have an alternative cause of their headache. Inflammatory markers can be normal initially. The limiting factor in biopsy negative cases is probably delay in obtaining a biopsy. Biopsy can be positive when the clinical suspicion is low, suggesting a low threshold for TAB is required. We suggest our model can be a useful template for similar clinical services.
Disclosure of Interest None Declared