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As concluded by Estrada et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> a good clinical assessment that classifies patients according to suspicion as high or low, together with the use of DUS, has led to an increase in diagnostic accuracy, allowing a reduction in the use of temporal artery biopsy (TAB) during the diagnostic process of GCA.</p><p id="par0010" class="elsevierStylePara elsevierViewall">This diagnostic revolution is conditioned by the accessibility of the different techniques: the universalisation of the use of DUS and the increased availability of positron emission tomography with computed tomography (PET/CT). All this in a context of generating new evidence to support current algorithms. The first American College of Rheumatology (ACR) classification criteria in 1990<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> included clinical, laboratory and temporal artery histopathology criteria, but not other complementary tests. In fact, even in 2021, the ACR continued to note the lack of evidence for the use of ancillary tests in the diagnosis of GCA and conditionally recommended the use of TAB before temporal artery DUS.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> On the other hand, in 2018, the European League Against Rheumatism (EULAR) recommended, with a high level of evidence, the performance of temporal artery DUS with/without axillary arteries as an initial imaging test in suspected GCA with a cranial phenotype, recommending other techniques in case of suspected GCA with systemic phenotype.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These recommendations argue that, although TAB has low morbidity and has been considered the gold standard for diagnosis, the use of DUS for the diagnosis of GCA is cost-effective. They do not make a recommendation against the use of TAB, but suggest that, in centres where another alternative (DUS) is available, the use of ultrasound should be prioritised. In fact, in the revision of these recommendations in 2023, they change the recommendation to DUS in both temporal arteries (TA) and axillary arteries (AA) and maintain the level of evidence.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> This recommendation is based on DUS's accessibility, low resource consumption and reliability when performed by expert hands. These proposals were supported by Mackie et al.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> in the British Society for Rheumatology (BSR) guidelines for the diagnosis and treatment of GCA, in which DUS was positioned as a possible first step in the diagnostic algorithm for GCA, although later in the text TAB and/or DUS were recommended as the first test to be performed.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The article by Estrada et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> mentions the need to establish a fast track for the diagnosis of this disease. This circuit must be available for the performance of DUS by trained and skilled personnel, at the same time as the first assessment or within 24–48 hours. These fast tracks have shown a decrease in severe complications of GCA, such as vision loss,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and early treatment can be initiated after an established diagnosis in case of high suspicion and compatible DUS. Alberts<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> also demonstrated the ability to reduce unnecessary tests, including TAB and its complications, in cases of low suspicion and normal DUS. There are still grey areas in those patients with high clinical suspicion and normal or indeterminate DUS, and in those with low suspicion and pathological or indeterminate DUS, and the authors recommend prioritising PET/CT over TAB.</p><p id="par0020" class="elsevierStylePara elsevierViewall">With regard to the diagnostic process, Estrada et al.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> used an algorithm that is in line with the proposed algorithm already presented by the BSR and confirmed by the Southend and Leeds groups<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and which has already been implemented in routine clinical practice. The currently published algorithm is simpler, relying on clinical data to classify suspicion as high/low without requiring laboratory results. This may be an advantage when assessing patients in case laboratory results are not available at the first assessment, although it should be noted that the proposed clinical criteria are, in their definition, more imprecise than those previously used.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,9</span></a> Multiple algorithms currently guide the diagnostic process in GCA, but it is unclear whether any one algorithm is superior to the other. The proposal by Estrada et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> as published in this issue, has shown that it is possible to classify patients well by reducing the tests required for this classification. On the other hand, the BSR group showed that the combination of the Southend pretest probability score and DUS results allows us to make a good diagnosis in clinical practice, with low misclassification rates.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Thus, it could be interesting to study the diagnostic performance of this cohort by comparing both algorithms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Currently, given the consensus on the use of ultrasound for the diagnosis of GCA, the new ACR/EULAR classification criteria of 2022 have included this technique, together with TAB and PET/CT, in the classification process.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In fact, both TA assessment and AA assessment are recommended, as discussed in the study by Estrada et al.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this regard, it has already been documented that the way in which patients with suspected GCA are assessed has changed in recent years, with DUS being performed more often in those patients with a more recent diagnosis of GCA.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In the future, the inclusion of other territories (carotid, vertebral or even intraorbital arteries) in the diagnostic process should probably also be considered, as this is known to increase the sensitivity of the test and facilitate diagnosis.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">GCA and polymyalgia rheumatica (PMR) are currently conceived as a spectrum of the same disease,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> and it is also known that the diagnostic performance of DUS, TAB and PET/CT are variable in different disease phenotypes.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16,17</span></a> The authors<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> classified the patients included in their study as high versus low suspicion and on the basis of clinical criteria. It would have been interesting to review the data and assess the usefulness of these scenarios in the different phenotypes. Constitutional symptoms or fever are symptoms that can sometimes lead to the diagnosis of the disease, although the way in which the diagnosis is made is likely to be different, with CT or PET/CT for neoplasm screening rather than DUS. In fact, there are now groups performing DUS on all patients with PMR, and they have shown that up to 20–25% of these patients have subclinical vasculitis.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The use of the different algorithms for the diagnosis of GCA after a good definition of the different disease subtypes in the GCA-PMR spectrum is, in our opinion, one of the future lines of work. Another line to be evaluated is the impact of studying other territories, such as the carotid or vertebral arteries, for the diagnosis of GCA, given their importance in ischaemic phenomena.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> In view of technical advances and improvements in the classification of GCA, it will be very interesting to find out how we diagnose our patients with GCA according to the reason for consultation and clinical expression.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0040" class="elsevierStylePara elsevierViewall">No patients were involved in the current manuscript and therefore no IRB approval or informed consent has been sought.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0045" class="elsevierStylePara elsevierViewall">The current manuscript has been produced without specific funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest in relation to the current manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:18 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utility of applying a diagnostic algorithm in giant cell arteritis based on the level of clinical suspicion" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. 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Journal Information
Vol. 163. Issue 3.
Pages 132-133 (August 2024)
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Vol. 163. Issue 3.
Pages 132-133 (August 2024)
Editorial
Doppler ultrasound in giant cell arteritis: More lights than shadows
Ecografía Doppler en el diagnóstico de la arteritis de células gigantes: más luces que sombras
Jaume Mestre-Torres
, Isidro Sanz-Pérez
Corresponding author
Servei de Medicina Interna, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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