Background/Purpose: The implementation of ultrasound (US) fast-track pathways (FTP), aiming at an early diagnosis of giant cell arteritis (GCA), has led to a decrease in permanent vision loss. However, the COVID-19 pandemic lockdown has had a negative impact in GCA patients, leading to a decline in referral rates of patients accompanied by cases with delayed presentation and vision loss.

The aim of our analysis was to assess the rate of US examinations included in our FTP and the rate of permanent visual loss due to GCA since the COVID-19 pandemic.

Methods: Retrospective observational study including patients referred to our US FTP for evaluation of possible GCA over a 16-month period. Visual loss due to anterior ischemic optic neuropathy (AION) confirmed by ophthalmology evaluation was checked. The gold standard for GCA diagnosis was the clinical confirmation after 6-months of follow-up. We compared the 8-month pre- and post- COVID-19 outbreak periods (July 2019 to February 2020 and March 2020 to October 2020).

Results: Since the beginning of the COVID-19 pandemic, 31 patients were referred to the FTP compared with 50 patients in the previous 8-months (38% reduction), although the service was regularly operating. The number of newly GCA diagnosis during the COVID-19 pandemic remained similar, although the percentage over the total examinations was higher (45.2% vs 22%; p=0.028). We found no notable differences in clinical referral patterns. However, it is noteworthy that 2 patients presented with AION during the COVID-19 pandemic, while noN AION in the previous period, although these differences were not statistically significant (p=0.14). During confinement, patients referred to the FTP presented higher C-reactive protein (7.6 vs 3.4 mg/dL; p=0.008), erythrocyte sedimentation rate (73.9 vs 45.7mm/h; p=0.02), platelets (342.1 vs 254.1 10⁹/L; p=0.001) and lower hemoglobin levels (11.7 vs 12.8 g/dL; p=0.019). We found that the halo and compression sign were more frequently found during the COVID-19 pandemic (38.7 vs 16%; p=0.021 and 25.8 vs 10%; p=0.06, respectively). It is also worth highlighting a higher proportion of positive temporal artery biopsy during the COVID-19 pandemic (50% vs 33% p=0.049).

Conclusion: Our data shows a reduction in utilization of GCA FTP since the COVID-19 outbreak and an increase of possibly preventable AION. US FTP has demonstrated to be useful in the reduction of permanent vision loss (1,4), so an impaired use of this tool may lead to worse outcomes. Our results go in line and confirm previous work that noticed a reduction in the requests for FTP assessments by May 2020 (3) . Although a higher proportion of patients referred to the FTP had GCA, the number of newly diagnosed GCA remained similar before and after the COVID-19 outbreak, in contrast with other studies that observed an increased number of GCA after the COVID-19 outbreak(5,6).

Our study highlights the potential risks of COVID-19 lockdown in the reduced referral of suspected GCA patients, the occurrence of permanent visual loss, and the need for maintaining urgent access to FTP during the COVID-19 pandemic

Figure 1. Number of patients evaluated in the fast-track pathway and number of newly GCA diagnosis over the study period.

Table 1. Clinical, laboratory and ultrasound findings of patients referred to the fast-track clinic for suspected GCA before and after lockdown.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/decreased-use-of-ultrasound-fast-track-pathways-of-giant-cell-arteritis-due-to-covid-19-pandemic-a-potential-risk-for-permanent-visual-loss/