Diagnostic delay for giant cell arteritis – a systematic review and meta-analysis

Abstract

BackgroundGiant cell arteritis (GCA), if untreated, can lead to blindness and stroke. The study’s objectives were to (1) determine a new evidence-based benchmark of the extent of diagnostic delay for GCA and (2) examine the role of GCA-specific characteristics on diagnostic delay.MethodsMedical literature databases were searched from inception to November 2015. Articles were included if reporting a time-period of diagnostic delay between onset of GCA symptoms and diagnosis. Two reviewers assessed the quality of the final articles and extracted data from these. Random-effects meta-analysis was used to pool the mean time-period (95% confidence interval (CI)) between GCA symptom onset and diagnosis, and the delay observed for GCA-specific characteristics. Heterogeneity was assessed by I 2 and by 95% prediction interval (PI).ResultsOf 4128 articles initially identified, 16 provided data for meta-analysis. Mean diagnostic delay was 9.0 weeks (95% CI, 6.5 to 11.4) between symptom onset and GCA diagnosis (I 2 = 96.0%; P < 0.001; 95% PI, 0 to 19.2 weeks). Patients with a cranial presentation of GCA received a diagnosis after 7.7 (95% CI, 2.7 to 12.8) weeks (I 2 = 98.4%; P < 0.001; 95% PI, 0 to 27.6 weeks) and those with non-cranial GCA after 17.6 (95% CI, 9.7 to 25.5) weeks (I 2 = 96.6%; P < 0.001; 95% PI, 0 to 46.1 weeks).ConclusionsThe mean delay from symptom onset to GCA diagnosis was 9 weeks, or longer when cranial symptoms were absent. Our research provides an evidence-based benchmark for diagnostic delay of GCA and supports the need for improved public awareness and fast-track diagnostic pathways.Electronic supplementary materialThe online version of this article (doi:10.1186/s12916-017-0871-z) contains supplementary material, which is available to authorized users.

A new era for giant cell arteritis

“…The mean diagnostic delay for those with cranial symptoms is 9 weeks and 17.6 weeks for patients presenting without cranial symptoms, due to a combination of multiple factors including delayed presentation, delayed clinical suspicion and delayed referral for specialist assessment and confirmatory diagnostic tests [68]. Public awareness of GCA is low and primary care doctors are faced with the often nonspecific nature of many early symptoms of GCA and a high prevalence of similar symptoms in the general consulting population [68]. If GCs are started, but specialist referral is delayed, then the potential for a secure diagnosis is reduced, the clinical signs may have resolved and the diagnostic tests are less likely to be positive with increasing time.…”

European Headache Federation recommendations for neurologists managing giant cell arteritis

“…The mean diagnostic delay for those with cranial symptoms is 9 weeks and for those presenting without cranial symptoms is over 17 weeks. There are many factors leading to delay, including delayed presentation, low clinical suspicion, belated referral for specialist assessment, and lack of access to confirmatory diagnostic tests [15]. General public awareness of GCA is low and the early symptoms of GCA are non-specific.…”

“…Clinically it can be difficult to diagnose, because the symptoms can be insidious [15,16]. Evidence suggests that increasing numbers of patients are being investigated for suspected GCA [17].…”

Vasculitis research: Current trends and future perspectives

“…Diagnosing GCA early is crucial to prevent irreversible vision loss . Therefore, a recent systematic review, which revealed a mean delay to diagnosis of 9 weeks in patients with GCA (7.7 weeks when patients had a cranial manifestations and 17.7 weeks with non‐cranial manifestations), is a matter of concern. There remains a need to improve strategies for early diagnosis of GCA.…”