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Tan MC, Yeo YH, Mirza N, San BJ, Tan JL, Lee JZ, Mazzarelli JK, Russo AM. Trends and Disparities in Cardiovascular Death in Sarcoidosis: A Population-Based Retrospective Study in the United States From 1999 to 2020. J Am Heart Assoc 2024; 13:e031484. [PMID: 38533928 PMCID: PMC11179790 DOI: 10.1161/jaha.123.031484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 12/06/2023] [Indexed: 03/28/2024]
Abstract
BACKGROUND Despite significant cardiac involvement in sarcoidosis, real-world data on death due to cardiovascular disease among patients with sarcoidosis is not well established. METHODS AND RESULTS We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for data on patients with sarcoidosis aged ≥25 years from 1999 to 2020. Diseases of the circulatory system except ischemic heart disease were listed as the underlying cause of death, and sarcoidosis was stated as a contributing cause of death. We calculated age-adjusted mortality rate (AAMR) per 1 million individuals and determined the trends over time by estimating the annual percentage change using the Joinpoint Regression Program. Subgroup analyses were performed on the basis of demographic and geographic factors. In the 22-year study period, 3301 cardiovascular deaths with comorbid sarcoidosis were identified. The AAMR from cardiovascular deaths with comorbid sarcoidosis increased from 0.53 (95% CI, 0.43-0.65) per 1 million individuals in 1999 to 0.87 (95% CI, 0.75-0.98) per 1 million individuals in 2020. Overall, women recorded a higher AAMR compared with men (0.77 [95% CI, 0.74-0.81] versus 0.58 [95% CI, 0.55-0.62]). People with Black ancestry had higher AAMR than people with White ancestry (3.23 [95% CI, 3.07-3.39] versus 0.39 [95% CI, 0.37-0.41]). A higher percentage of death was seen in the age groups of 55 to 64 years in men (23.11%) and women (21.81%), respectively. In terms of US census regions, the South region has the highest AAMR from cardiovascular deaths with comorbid sarcoidosis compared with other regions (0.78 [95% CI, 0.74-0.82]). CONCLUSIONS The increase of AAMR from cardiovascular deaths with comorbid sarcoidosis and higher cardiovascular mortality rates among adults aged 55 to 64 years highlight the importance of early screening for cardiovascular diseases among patients with sarcoidosis.
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Affiliation(s)
- Min Choon Tan
- Department of Internal MedicineNew York Medical College at Saint Michael’s Medical CenterNewarkNJUSA
- Department of Cardiovascular MedicineMayo ClinicPhoenixAZUSA
| | - Yong Hao Yeo
- Department of Internal Medicine/PediatricsBeaumont HealthRoyal OakMIUSA
| | - Noreen Mirza
- Department of Internal MedicineNew York Medical College at Saint Michael’s Medical CenterNewarkNJUSA
| | | | - Jian Liang Tan
- Department of Cardiovascular MedicineHospital of the University of PennsylvaniaPhiladelphiaPAUSA
| | - Justin Z. Lee
- Department of Cardiovascular MedicineCleveland ClinicClevelandOHUSA
| | - Joanne K. Mazzarelli
- Department of MedicineCooper University Health System/Cooper Medical School of Rowan UniversityCamdenNJUSA
| | - Andrea M. Russo
- Department of MedicineCooper University Health System/Cooper Medical School of Rowan UniversityCamdenNJUSA
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Skowasch D, Bonella F, Buschulte K, Kneidinger N, Korsten P, Kreuter M, Müller-Quernheim J, Pfeifer M, Prasse A, Quadder B, Sander O, Schupp JC, Sitter H, Stachetzki B, Grohé C. [Therapeutic Pathways in Sarcoidosis. A Position Paper of the German Society of Respiratory Medicine (DGP)]. Pneumologie 2024; 78:151-166. [PMID: 38408486 DOI: 10.1055/a-2259-1046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
The present recommendations on the therapy of sarcoidosis of the German Respiratory Society (DGP) was written in 2023 as a German-language supplement and update of the international guidelines of the European Respiratory Society (ERS) from 2021. It contains 5 PICO questions (Patients, Intervention, Comparison, Outcomes) agreed in the consensus process, which are explained in the background text of the four articles: Confirmation of diagnosis and monitoring of the disease under therapy, general therapy recommendations, therapy of cutaneous sarcoidosis, therapy of cardiac sarcoidosis.
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Affiliation(s)
- Dirk Skowasch
- Medizinische Klinik und Poliklinik II - Sektion Pneumologie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Francesco Bonella
- Zentrum für interstitielle und seltene Lungenerkrankungen, Klinik für Pneumologie, Ruhrlandklinik, Universitätsmedizin Essen, Essen, Deutschland
| | - Katharina Buschulte
- Zentrum für seltene und interstitielle Lungenerkrankungen, Thoraxklinik, Universitätsklinikum Heidelberg und Deutsches Zentrum für Lungenforschung (DZL) - Heidelberg, Deutschland
| | - Nikolaus Kneidinger
- Lungentransplantation und interstitielle Lungenerkrankungen, Medizinische Klinik und Poliklinik V, München, Deutschland
| | - Peter Korsten
- Klinische Rheumatologie und rheumatologische Intensivmedizin, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Michael Kreuter
- Lungenzentrum Mainz, Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Marienhaus Klinikum Mainz und Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Joachim Müller-Quernheim
- Klinik für Pneumologie, Department Innere Medizin, Uniklinik Freiburg, Medizinische Fakultät, Freiburg, Deutschland
| | - Michael Pfeifer
- Innere Medizin, Lungen- und Bronchialheilkunde, Krankenhaus Barmherzige Brüder, Regensburg, Deutschland
| | - Antje Prasse
- Lungenfibrose und interstitielle Lungenerkrankungen, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Bernd Quadder
- Deutsche Sarkoidose-Vereinigung, gemeinnütziger e. V. (DSV)
| | - Oliver Sander
- Klinik für Rheumatologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - Jonas C Schupp
- Respiratory and Infectious Medicine, Hannover Medical School, Hannover, Germany
| | - Helmut Sitter
- Institut für Chirurgische Forschung, Fachbereich Medizin, Philipps-Universität Marburg, Marburg, Deutschland
| | | | - Christian Grohé
- Klinik für Pneumologie, Evangelische Lungenklinik, Berlin, Deutschland
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Tan MC, Ang QX, Yeo YH, San BJ, Ibrahim R, Ng SJ, Tan JL, Walia J, Suleiman A, Correia J. Impact of Sarcoidosis on In-hospital Outcomes Among Patients with Atrial Fibrillation: A Nationwide Readmissions Database Analysis. J Innov Card Rhythm Manag 2024; 15:5782-5785. [PMID: 38584749 PMCID: PMC10994093 DOI: 10.19102/icrm.2024.15035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/10/2023] [Indexed: 04/09/2024] Open
Abstract
Sarcoidosis is a disease that involves multiple organs, including the cardiovascular system. While cardiac sarcoidosis has been increasingly recognized, the impact of sarcoidosis on atrial fibrillation (AF) is not well established. This study aimed to analyze the impact of sarcoidosis on in-hospital outcomes among patients who were admitted for a primary diagnosis of AF. Using the all-payer, nationally representative Nationwide Readmissions Database, our study included patients aged ≥18 years who were admitted for AF between 2017-2020. We stratified the cohort into two groups depending on the presence of sarcoidosis diagnosis. The in-hospital outcomes were assessed between the two groups via propensity score analysis. A total of 1031 (0.27%) AF patients with sarcoidosis and 387,380 (99.73%) AF patients without sarcoidosis were identified in our analysis. Our propensity score analysis of 1031 (50%) patients with AF and sarcoidosis and 1031 (50%) patients with AF but without sarcoidosis revealed comparable outcomes in early mortality (1.55% vs. 1.55%, P = 1.000), prolonged hospital stay (9.51% vs. 9.70%, P = .874), non-home discharge (7.95% vs. 9.89%, P = .108), and 30-day readmission (13.29% vs. 13.69%, P = .797) between the two groups. The cumulative cost of hospitalization was also similar in both groups ($12,632.25 vs. $12,532.63, P = .839). The in-hospital adverse event rates were comparable in both groups. Sarcoidosis is not a risk factor for poorer in-hospital outcomes following AF admission. These findings provide valuable insights into the effectiveness of the current guideline for AF management in patients with concomitant sarcoidosis and AF.
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Affiliation(s)
- Min Choon Tan
- Department of Internal Medicine, New York Medical College at Saint Michael’s Medical Center, Newark, NJ, USA
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Qi Xuan Ang
- Department of Internal Medicine, Sparrow Health System and Michigan State University, East Lansing, MI, USA
| | - Yong Hao Yeo
- Department of Internal Medicine/Pediatrics, Beaumont Health, Royal Oak, MI, USA
| | | | - Ramzi Ibrahim
- Department of Internal Medicine, University of Arizona—Banner University Medical Center, Tucson, AZ, USA
| | - Sze Jia Ng
- Department of Internal Medicine, Crozer-Chester Medical Center, Upland, PA, USA
| | - Jian Liang Tan
- Department of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jasjit Walia
- Department of Cardiovascular Medicine, New York Medical College at Saint Michael’s Medical Center, Newark, NJ, USA
| | - Addi Suleiman
- Department of Cardiovascular Medicine, New York Medical College at Saint Michael’s Medical Center, Newark, NJ, USA
| | - Joaquim Correia
- Department of Cardiovascular Medicine, New York Medical College at Saint Michael’s Medical Center, Newark, NJ, USA
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Morimoto R, Unno K, Fujita N, Sakuragi Y, Nishimoto T, Yamashita M, Kuwayama T, Hiraiwa H, Kondo T, Kuwatsuka Y, Okumura T, Ohshima S, Takahashi H, Ando M, Ishii H, Kato K, Murohara T. Prospective Analysis of Immunosuppressive Therapy in Cardiac Sarcoidosis With Fluorodeoxyglucose Myocardial Accumulation: The PRESTIGE Study. JACC Cardiovasc Imaging 2024; 17:45-58. [PMID: 37452820 DOI: 10.1016/j.jcmg.2023.05.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 05/16/2023] [Accepted: 05/23/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Fluorodeoxyglucose positron emission tomography (18F-FDG-PET) can noninvasively assess active inflammatory myocardium in patients with cardiac sarcoidosis (CS). Prednisolone (PSL) is the initial drug of choice for active CS; however, its efficacy has not been prospectively evaluated. Moreover, there are no alternative systematic treatment strategies. OBJECTIVES The goal of this study was to evaluate the efficacy of methotrexate (MTX) in patients refractory to PSL assessed by using cardiac metabolic activity (CMA) in 18F-FDG-PET. METHODS A total of 59 patients with active CS were prospectively enrolled. CMA (standardized uptake value × accumulation area) was used as an indicator of active inflammation, and a 6-month regimen of PSL therapy was introduced, followed by a second FDG scan. Poor responders to PSL therapy (CMA reduction rate <70%) and patients with recurrent CS (CMA reduction rate ≥70% after initial PSL therapy but CMA recurred after an additional 6 months of therapy) were randomly assigned to the MTX or repeat PSL (re-PSL) therapy groups for another 6 months. RESULTS Fifty-six patients completed the initial 6-month PSL therapy regimen. Median CMA reduced from 203.3 to 1.0 (P < 0.001), and 47 patients were allocated to the response group, 9 to the poor response group, and 2 to the recurrent group. Accordingly, 11 patients were randomly assigned to the MTX (n = 5) or re-PSL (n = 6) groups. After 6 months, neither group showed a significant reduction in CMA values. MTX was comparable to re-PSL in reducing CMA. CONCLUSIONS The 6-month regimen of PSL was a potent therapeutic tool for active CS. When MTX was added to low-dose PSL in patients refractory to the initial PSL therapy, there was no significant difference compared with re-PSL. Further studies are needed to evaluate the therapeutic potential of MTX for active CS, including how MTX works when it is administered in higher doses or for longer periods.
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Affiliation(s)
- Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kazumasa Unno
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; Department of Cardiology, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan.
| | - Naotoshi Fujita
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Yasuhiro Sakuragi
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Takuya Nishimoto
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Masato Yamashita
- Department of Radiological Technology, Nagoya University Hospital, Nagoya, Japan
| | - Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Yachiyo Kuwatsuka
- Department of Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Satoru Ohshima
- Department of Cardiology, Nagoya Kyoritsu Hospital, Nagoya, Japan
| | - Hiroshi Takahashi
- Department of Cardiology, Fujita Health University School of Medicine, Toyoake, Japan
| | - Masahiko Ando
- Department of Advanced Medicine and Clinical Research, Nagoya University Hospital, Nagoya, Japan
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Katsuhiko Kato
- Department of Functional Medical Imaging, Biomedical Imaging Sciences, Division of Advanced Information Health Sciences, Department of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Kacprzak A, Tomkowski W, Szturmowicz M. Phenotypes of Sarcoidosis-Associated Pulmonary Hypertension-A Challenging Mystery. Diagnostics (Basel) 2023; 13:3132. [PMID: 37835874 PMCID: PMC10572558 DOI: 10.3390/diagnostics13193132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Sarcoidosis has been a well-recognised risk factor for pulmonary hypertension (PH) for a long time, but still, the knowledge about this concatenation is incomplete. Sarcoidosis-associated PH (SAPH) is an uncommon but serious complication associated with increased morbidity and mortality among sarcoidosis patients. The real epidemiology of SAPH remains unknown, and its pathomechanisms are not fully explained. Sarcoidosis is a heterogeneous and dynamic condition, and SAPH pathogenesis is believed to be multifactorial. The main roles in SAPH development play: parenchymal lung disease with the destruction of pulmonary vessels, the extrinsic compression of pulmonary vessels by conglomerate masses, lymphadenopathy or fibrosing mediastinitis, pulmonary vasculopathy, LV dysfunction, and portal hypertension. Recently, it has been recommended to individually tailor SAPH management according to the predominant pathomechanism, i.e., SAPH phenotype. Unfortunately, SAPH phenotyping is not a straightforward process. First, there are gaps in our understanding of undergoing processes. Second, the assessment of such a pivotal element as pulmonary vasculature on a microscopic level is non-feasible in SAPH patients antemortem. Finally, SAPH is a dynamic condition, multiple phenotypes usually coexist, and patients can switch between phenotypes during the course of sarcoidosis. In this article, we summarise the basic knowledge of SAPH, describe SAPH phenotypes, and highlight some practical problems related to SAPH phenotyping.
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Affiliation(s)
- Aneta Kacprzak
- 1st Department of Lung Diseases, National Tuberculosis and Lung Diseases Institute, Plocka 26, 01-138 Warsaw, Poland
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Arps K, Doss J, Geiger K, Flores-Rosario K, DeVore AD, Karra R, Kim HW, Piccini JP, Pokorney SD, Sun AY. Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis. Am J Cardiol 2023; 204:249-256. [PMID: 37556894 DOI: 10.1016/j.amjcard.2023.07.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/13/2023] [Indexed: 08/11/2023]
Abstract
Cardiac sarcoidosis (CS) is a relapsing-remitting disease, and immune suppression (IS) is the mainstay of therapy. Predictors of relapse for patients with CS in remission are not well characterized. We assessed incidence of relapse in consecutive patients with CS treated with high-dose steroids and/or steroid-sparing agents (SSA) in our center from 2000 to 2020. Remission was defined as reaching maintenance therapy (no IS, SSA, and/or prednisone ≤5 mg/d) for ≥1 month. Relapse was defined as recurrence of CS syndrome requiring IS intensification: heart failure, ventricular arrhythmia, decrease in left ventricular ejection fraction, or increased disease burden on imaging. Among 68 patients, the mean age was 50.7±9.0 years; 25 (37%) were women, and 32 (47%) were Black. In total, 59 patients (87%) reached remission. Over a median follow-up of 39.5 months (interquartile range 17.6, 92.5), 28 (48%) relapsed. Greater percentage of late gadolinium enhancement (LGE) on pretreatment magnetic resonance imaging corresponded with increased likelihood of relapse (odds ratio 1.396 per 5% increase [95% confidence interval (CI) 1.04 to 1.88]; p = 0.028). LGE ≥11% predicted elevated risk of relapse (adjusted odds ratio 4.998 [1.34 to 18.64]; p = 0.017). Shorter time to relapse was observed with isolated CS (adjusted hazard ratio 4.084 [1.44,11.56]; p = 0.008) and LGE ≥11% (adjusted hazard ratio 3.007 [1.01, 8.98]; p = 0.049). Approximately 1 in 2 patients with CS in remission experienced relapse. Greater burden of LGE on cardiac magnetic resonance imaging and isolated CS are associated with greater risk of relapse. Future work is needed to refine risk stratification for relapse and to optimize surveillance strategies on the basis of the burden of disease.
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Affiliation(s)
- Kelly Arps
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Jayanth Doss
- Duke University Medical Center, Durham, North Carolina
| | - Kelly Geiger
- Duke University Medical Center, Durham, North Carolina
| | | | - Adam D DeVore
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Ravi Karra
- Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Sean D Pokorney
- Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Albert Y Sun
- Duke University Medical Center, Durham, North Carolina; Durham Veterans Affairs Medical Center, Durham, North Carolina
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Abstract
Sarcoidosis is a granulomatous disease with the potential of multiple organ system involvement and its etiology remains unknown. Cardiac involvement is associated with worse clinical outcome, and has been reported to be 20-30% in white and as high as 58% in Japanese populations with sarcoidosis. Clinical manifestations of cardiac sarcoidosis highly depend on the extent and location of granulomatous inflammation. The most frequent presentations include heart block, tachyarrhythmia, or heart failure. Endomyocardial biopsy is the most specific diagnostic test, but has poor sensitivity due to often patchy involvement. The diagnosis of cardiac sarcoidosis remains challenging due to nonspecific imaging findings. Both 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and cardiac magnetic resonance imaging can be used to evaluate cardiac sarcoidosis, but evaluate different stages of the disease process. FDG-PET detects metabolically active inflammatory cells while cardiac magnetic resonance imaging with late gadolinium enhancement reveals areas of myocardial necrosis and fibrosis. Aggressive therapy of symptomatic cardiac sarcoidosis is often sought due to the high risk of sudden death and/or progression to heart failure. Prednisone 20-40 mg a day is the recommended initial treatment. In refractory or severe cases, higher doses of prednisone, 1-1.5 mg/kg/d (or its equivalent) and addition of a steroid-sparing agent have been utilized. Methotrexate is added most commonly. Long-term improvement has been reported with the use of a combination of weekly methotrexate and prednisone versus prednisone alone. After initiation of treatment, a cardiac FDG-PET scan may be performed 2-3 months later to assess treatment response.
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Affiliation(s)
- Chengyue Jin
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Liliya Gandrabur
- Division of Rheumatology, Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Woo Young Kim
- From the Department of Medicine, Westchester Medical Center, Valhalla, NY
| | - Stephen Pan
- Department of Medicine and Cardiology, Westchester Medical Center, Valhalla, NY
| | - Julia Y Ash
- Division of Rheumatology, Department of Medicine, Westchester Medical Center, Valhalla, NY
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Wiefels C, Weng W, Beanlands R, deKemp R, Nery PB, Boczar K, Mesquita CT, Birnie D. Investigating the treatment phenotypes of cardiac sarcoidosis: A prospective cohort study. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 24:None. [PMID: 37441681 PMCID: PMC10333413 DOI: 10.1016/j.ahjo.2022.100224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 07/15/2023]
Abstract
Introduction Data indicates there are 4 main pulmonary sarcoidosis duration/treatment phenotypes: asymptomatic, acute (disease duration <1-2 years), chronic and advanced. There are no data about disease duration/treatment phenotypes of cardiac sarcoidosis patients. Our study had 2 main aims (i) to assess the response to corticosteroids and (ii) to assess the incidence of relapse after a one-year course of corticosteroids (thereby classifying patients as acute or chronic treatment phenotype). Methods Consecutive, treatment naive patients with CS were prospectively recruited and treated with 0.5 mg/kg prednisone, to a maximum dose of 40 mg/day. Patients had a follow-up PET after 3-6 months of therapy (PET 2). In the responders (PET definition of response) the prednisone was then weaned and stopped after 12 months. Three months after stopping, the PET was repeated to look for disease relapse (PET 3). Results Twenty-one consecutive patients were included, and all patients showed a reduction in cardiac FDG uptake after 3-6 months and 19/21 (90.5 %) met the PET definition of response. Of these, 12/19 (63.1 %) relapsed after prednisone was stopped. There were no serious adverse effects during the trial of therapy cessation and there were no later relapses in the 7 non-relapsers during over 4 years of subsequent follow-up. Conclusion The initial response rate to prednisone was high with all patients showing a reduction in FDG uptake and 19/21 meeting a PET definition of >25 % response. Secondly, a trial of therapy discontinuation was able to classify 7/19 patients as acute treatment phenotype and 12/19 as chronic.
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Affiliation(s)
- Christiane Wiefels
- University of Ottawa, Department of Medicine, Division of Nuclear Medicine, Ottawa, ON, Canada
- Universidade Federal Fluminense, Pós-Graduação em Ciências Cardiovasculares, Niterói, Rio de Janeiro, Brazil
| | - Willy Weng
- University of Ottawa Heart Institute, Arrhythmia Service, Division of Cardiology, Department of Medicine, Ottawa, ON, Canada
| | - Rob Beanlands
- University of Ottawa Heart Institute, The National Cardiac PET Center, Department of Medicine, Division of Cardiology, Ottawa, ON, Canada
| | - Rob deKemp
- University of Ottawa Heart Institute, The National Cardiac PET Center, Department of Medicine, Division of Cardiology, Ottawa, ON, Canada
| | - Pablo B. Nery
- University of Ottawa Heart Institute, Arrhythmia Service, Division of Cardiology, Department of Medicine, Ottawa, ON, Canada
| | - Kevin Boczar
- University of Ottawa Heart Institute, The National Cardiac PET Center, Department of Medicine, Division of Cardiology, Ottawa, ON, Canada
| | - Claudio Tinoco Mesquita
- Universidade Federal Fluminense, Pós-Graduação em Ciências Cardiovasculares, Niterói, Rio de Janeiro, Brazil
| | - David Birnie
- University of Ottawa Heart Institute, Arrhythmia Service, Division of Cardiology, Department of Medicine, Ottawa, ON, Canada
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Liang H, Ning G, Dai S, Ma L, Luo J, Zhang X, Liao H. Spatiotemporal reconstruction method of carotid artery ultrasound from freehand sonography. Int J Comput Assist Radiol Surg 2022; 17:1731-1743. [PMID: 35704237 DOI: 10.1007/s11548-022-02672-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Accepted: 05/02/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE 4D reconstruction based on radiation-free ultrasound can provide valuable information about the anatomy. Current 4D US technologies are either faced with limited field-of-view (FoV), technical complications, or cumbersome setups. This paper proposes a spatiotemporal US reconstruction framework to enhance its ability to provide dynamic structure information. METHODS We propose a spatiotemporal US reconstruction framework based on freehand sonography. First, a collecting strategy is presented to acquire 2D US images in multiple spatial and temporal positions. A morphology-based phase extraction method after pose correction is presented to decouple the compounding image variations. For temporal alignment and reconstruction, a robust kernel regression model is established to reconstruct images in arbitrary phases. Finally, the spatiotemporal reconstruction is demonstrated in the form of 4D movies by integrating the US images according to the tracked poses and estimated phases. RESULTS Quantitative and qualitative experiments were conducted on the carotid US to validate the feasibility of the proposed pipeline. The mean phase localization and heart rate estimation errors were 0.07 ± 0.04 s and 0.83 ± 3.35 bpm, respectively, compared with cardiac gating signals. The assessment of reconstruction quality showed a low RMSE (<0.06) between consecutive images. Quantitative comparisons of anatomy reconstruction from the generated US volumes and MRI showed an average surface distance of 0.39 ± 0.09 mm on the common carotid artery and 0.53 ± 0.05 mm with a landmark localization error of 0.60 ± 0.18 mm on carotid bifurcation. CONCLUSION A novel spatiotemporal US reconstruction framework based on freehand sonography is proposed that preserves the utility nature of conventional freehand US. Evaluations on in vivo datasets indicated that our framework could achieve acceptable reconstruction performance and show potential application value in the US examination of dynamic anatomy.
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Affiliation(s)
- Hanying Liang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Guochen Ning
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Shangqi Dai
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Longfei Ma
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Jianwen Luo
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Xinran Zhang
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China
| | - Hongen Liao
- Department of Biomedical Engineering, School of Medicine, Tsinghua University, Beijing, 100084, China.
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Savale L, Huitema M, Shlobin O, Kouranos V, Nathan SD, Nunes H, Gupta R, Grutters JC, Culver DA, Post MC, Ouellette D, Lower EE, Al-Hakim T, Wells AU, Humbert M, Baughman RP. WASOG statement on the diagnosis and management of sarcoidosis-associated pulmonary hypertension. Eur Respir Rev 2022; 31:31/163/210165. [PMID: 35140103 DOI: 10.1183/16000617.0165-2021] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/13/2021] [Indexed: 12/14/2022] Open
Abstract
Sarcoidosis-associated pulmonary hypertension (SAPH) is an important complication of advanced sarcoidosis. Over the past few years, there have been several studies dealing with screening, diagnosis and treatment of SAPH. This includes the results of two large SAPH-specific registries. A task force was established by the World Association of Sarcoidosis and Other Granulomatous disease (WASOG) to summarise the current level of knowledge in the area and provide guidance for the management of patients. A group of sarcoidosis and pulmonary hypertension experts participated in this task force. The committee developed a consensus regarding initial screening including who should undergo more specific testing with echocardiogram. Based on the results, the committee agreed upon who should undergo right-heart catheterisation and how to interpret the results. The committee felt there was no specific phenotype of a SAPH patient in whom pulmonary hypertension-specific therapy could be definitively recommended. They recommended that treatment decisions be made jointly with a sarcoidosis and pulmonary hypertension expert. The committee recognised that there were significant defects in the current knowledge regarding SAPH, but felt the statement would be useful in directing future studies.
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Affiliation(s)
- Laurent Savale
- Université Paris-Saclay; INSERM UMR_S 999; Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Marloes Huitema
- Dept of Cardiology, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | - Oksana Shlobin
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Vasilis Kouranos
- Interstitial Lung Disease/Sarcoidosis Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Steven D Nathan
- Advanced Lung Disease and Transplant Program, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Hiliaro Nunes
- INSERM UMR 1272, Université Sorbonne Paris Nord; Service de Pneumologie, Centre de Référence des Maladies Pulmonaires Rares, APHP, Hôpital Avicenne, Bobigny, France
| | - Rohit Gupta
- Dept of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA USA
| | - Jan C Grutters
- Dept of Pulmonology, ILD Center of Excellence, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Marco C Post
- Dept of Cardiology, St. Antonius Hospital, Nieuwegein and University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Elyse E Lower
- Dept of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | | | - Athol U Wells
- Interstitial Lung Disease/Sarcoidosis Unit, Royal Brompton Hospital, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Marc Humbert
- Université Paris-Saclay; INSERM UMR_S 999; Assistance Publique Hôpitaux de Paris, Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | - Robert P Baughman
- Dept of Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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11
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Desbois A, Charpentier E, Chapelon C, Bergeret S, Badenco N, Redheuil A, Cacoub P, Saadoun D. Sarcoïdose cardiaque : stratégies diagnostiques et thérapeutiques actuelles. Rev Med Interne 2022; 43:212-224. [DOI: 10.1016/j.revmed.2021.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/22/2021] [Accepted: 08/01/2021] [Indexed: 11/26/2022]
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12
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Stievenart J, Le Guenno G, Ruivard M, Rieu V, André M, Grobost V. Cardiac sarcoidosis: systematic review of literature on corticosteroid and immunosuppressive therapies. Eur Respir J 2021; 59:13993003.00449-2021. [PMID: 34531273 PMCID: PMC9068974 DOI: 10.1183/13993003.00449-2021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 08/26/2021] [Indexed: 11/26/2022]
Abstract
Background Cardiac sarcoidosis (CS) is a life-threatening condition in which clear recommendations are lacking. We aimed to systematically review the literature on cardiac sarcoidosis treated by corticosteroids and/or immunosuppressive agents in order to update the management of CS. Methods Using PubMed, Embase and Cochrane Library databases, we found original articles on corticosteroid and standard immunosuppressive therapies for CS that provided at least a fair Scottish Intercollegiate Guidelines Network (SIGN) overall assessment of quality and we analysed the relapse rate, major cardiac adverse events (MACEs) and adverse events. We based our methods on the PRISMA statement and checklist. Results We retrieved 21 studies. Mean quality provided by SIGN assessment was 6.8 out of 14 (range 5–9). Corticosteroids appeared to have a positive impact on left ventricular function, atrioventricular block and ventricular arrhythmias. For corticosteroids alone, nine studies (45%, n=351) provided data on relapses, representing an incidence of 34% (n=119). Three studies (14%, n=73) provided data on MACEs (n=33), representing 45% of MACEs in patients treated by corticosteroid alone. Nine studies provided data on adjunctive immunosuppressive therapy, of which four studies (n=78) provided data on CS relapse, representing an incidence of 33% (n=26). Limitations consisted of no randomised control trial retrieved and unclear data on MACEs in patients treated by combined immunosuppressive agents and corticosteroids. Conclusion Corticosteroids should be started early after diagnosis but the exact scheme is still unclear. Studies concerning adjunctive conventional immunosuppressive therapies are lacking and benefits of adjunctive immunosuppressive therapies are unclear. Homogenous data on CS long-term outcomes under corticosteroids, immunosuppressive therapies and other adjunctive therapies are lacking. Corticosteroids are the mainstay treatment for cardiac sarcoidosis. Conventional immunosuppressive agents might be of interest at diagnosis. Cohort studies are clearly heterogeneous. Large cohort and prospective studies using “strong” end-points are lacking.https://bit.ly/3t9Rv8O
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Affiliation(s)
- Julien Stievenart
- Internal Medicine Department, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Clermont-Ferrand, France
| | - Guillaume Le Guenno
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Marc Ruivard
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Virginie Rieu
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
| | - Marc André
- Internal Medicine Department, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Clermont-Ferrand, France.,Université Clermont Auvergne, Clermont-Ferrand University Hospital, 58 Avenue Montalembert, Inserm U1071, INRA USC2018, M2iSH, Clermont-Ferrand, France
| | - Vincent Grobost
- Internal Medicine Department, Clermont-Ferrand University Hospital, 1 Rue Lucie et Raymond Aubrac, Clermont-Ferrand, France
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13
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Fazelpour S, Sadek MM, Nery PB, Beanlands RS, Tzemos N, Toma M, Birnie DH. Corticosteroid and Immunosuppressant Therapy for Cardiac Sarcoidosis: A Systematic Review. J Am Heart Assoc 2021; 10:e021183. [PMID: 34472360 PMCID: PMC8649244 DOI: 10.1161/jaha.121.021183] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/22/2021] [Indexed: 11/16/2022]
Abstract
Background Corticosteroid therapy for the treatment of clinically manifest cardiac sarcoidosis is generally recommended. Our group previously systematically reviewed the data in 2013; since then, there has been increasing quality and quantity of data and also interest in nonsteroid agents. Methods and Results Studies were identified from MEDLINE, EMBASE, Cochrane Controlled Trials Register, Cochrane Database of Systematic Reviews, and the National Institutes of Health ClinicalTrials.gov database. The quality of included articles was rated using Scottish Intercollegiate Guidelines Network 50. Outcomes examined were atrioventricular conduction, left ventricular function, ventricular arrhythmias, and mortality. A total of 3527 references were retrieved, and 34 publications met the inclusion criteria. There were no randomized trials, and only 2 studies were rated good quality. In the 34 reports (total of 1297 patients), 1125 patients received corticosteroids, 235 received additional or other immunosuppressant therapy, and 97 patients received no therapy. There were 178 patients treated for atrioventricular conduction disease, with 76/178 (42.7%) improving. In contrast, 21 patients were not treated with corticosteroids and/or immunosuppressant therapy, and none of them improved. Therapy was associated with the prevention of deterioration in left ventricular function. A total of 8 publications reported on ventricular arrhythmia burden, and 19 reported on mortality; the data quality was too limited to draw conclusions for the latter 2 outcomes. Conclusions The best quality data relate to atrioventricular nodal conduction and left ventricular function recovery. In both situations, therapy with corticosteroids and/or immunosuppressant therapy were sometimes associated with positive outcomes. The data quality is too limited to draw conclusions for ventricular arrhythmias and mortality.
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Affiliation(s)
- Siavosh Fazelpour
- Arrhythmia ServiceDivision of CardiologyDepartment of MedicineUniversity of Ottawa Heart InstituteOttawaOntarioCanada
- Division of CardiologyDepartment of MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Mouhannad M. Sadek
- Arrhythmia ServiceDivision of CardiologyDepartment of MedicineUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Pablo B. Nery
- Arrhythmia ServiceDivision of CardiologyDepartment of MedicineUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Rob S. Beanlands
- Division of CardiologyDepartment of MedicineThe National Cardiac PET CenterUniversity of Ottawa Heart InstituteOttawaOntarioCanada
| | - Niko Tzemos
- Division of CardiologyLondon Health SciencesUniversity of Western OntarioLondonOntarioCanada
| | - Mustafa Toma
- Division of CardiologySt. Paul's HospitalUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - David H. Birnie
- Arrhythmia ServiceDivision of CardiologyDepartment of MedicineUniversity of Ottawa Heart InstituteOttawaOntarioCanada
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14
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Viwe M, Nery P, Birnie DH. Management of ventricular tachycardia in patients with cardiac sarcoidosis. Heart Rhythm O2 2021; 2:412-422. [PMID: 34430947 PMCID: PMC8369307 DOI: 10.1016/j.hroo.2021.07.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease with 2 different phases (inflammation and scar). In the current era of targeted use of implantable cardioverter-defibrillators and modern heart failure therapy, recent data indicate the prognosis of cardiac sarcoidosis (CS) is much improved, and hence more patients are presenting with recurrent ventricular tachycardia (VT). This review highlights our current understanding of the pathophysiology and management of ventricular arrhythmias in CS with the major focus on indications, techniques, and outcomes of ablation. It is likely macroreentry phenomena around areas of fibrosis is the most frequent mechanism of ventricular arrhythmia in CS. It is also possible that inflammation may play a role in initiating reentry with ventricular ectopy in CS patients, or by slowing conduction in diseased tissue. The best available data would suggest annual rates of VT of perhaps 1%-2% and 10%-15% in patients with initially clinically silent and clinically manifest disease, respectively. Current guidelines recommend a stepwise approach to VT management. The first suggested step is treatment with immunosuppression if there is evidence of active inflammation. Antiarrhythmic medications are often started at the same time, with catheter ablation considered if VT cannot be controlled. Activation and entrainment mapping and ablation are favored in the setting of hemodynamically tolerated VT. Substrate ablation targets areas of abnormal electrogram and favorable pace mapping using linear and/or cluster lesion sets with the goal of abolishing critical isthmuses and/or blocking VT exit sites. Epicardial mapping ablation is required in 20%-35% of cases. In general, more morphologies of VT are induced (often 3-4) and subsequent outcomes (recurrence rates 40%-50%) are less favorable than in other forms of nonischemic cardiomyopathy. The prognosis of CS is much improved and, as a result, more patients are developing VT during follow-up. Likely principally related to the complex disease substrate, VT ablation is technically challenging, with moderate outcomes, and much remains to be learned.
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Affiliation(s)
- Mtwesi Viwe
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Canada
- Division of Cardiology, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Pablo Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
| | - David H. Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Canada
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15
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ERS clinical practice guidelines on treatment of sarcoidosis. Eur Respir J 2021; 58:13993003.04079-2020. [PMID: 34140301 DOI: 10.1183/13993003.04079-2020] [Citation(s) in RCA: 211] [Impact Index Per Article: 70.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 05/04/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND The major reasons to treat sarcoidosis are to lower the morbidity and mortality risk or to improve quality of life (QoL). The indication for treatment varies depending on which manifestation is the cause of symptoms: lungs, heart, brain, skin, or other manifestations. While glucocorticoids (GC) remain the first choice for initial treatment of symptomatic disease, prolonged use is associated with significant toxicity. GC-sparing alternatives are available. The presented treatment guideline aims to provide guidance to physicians treating the very heterogenous sarcoidosis manifestations. MATERIALS AND METHODS A European Respiratory Society Task Force (TF) committee composed of clinicians, methodologists, and patients with experience in sarcoidosis developed recommendations based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluations) methodology. The committee developed eight PICO (Patients, Intervention, Comparison, Outcomes) questions and these were used to make specific evidence-based recommendations. RESULTS The TF committee delivered twelve recommendations for seven PICOs. These included treatment of pulmonary, cutaneous, cardiac, and neurologic disease as well as fatigue. One PICO question regarding small fiber neuropathy had insufficient evidence to support a recommendation. In addition to the recommendations, the committee provided information on how they use alternative treatments, when there was insufficient evidence to support a recommendation. CONCLUSIONS There are many treatments available to treat sarcoidosis. Given the diverse nature of the disease, treatment decisions require an assessment of organ involvement, risk for significant morbidity, and impact on QoL of the disease and treatment. MESSAGE An evidence based guideline for treatment of sarcoidosis is presented. The panel used the GRADE approach and specific recommendations are made. A major factor in treating patients is the risk of loss of organ function or impairment of quality of life.
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16
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Gallegos C, Oikonomou EK, Grimshaw A, Gulati M, Young BD, Miller EJ. Non-steroidal treatment of cardiac sarcoidosis: A systematic review. IJC HEART & VASCULATURE 2021; 34:100782. [PMID: 33997256 PMCID: PMC8105294 DOI: 10.1016/j.ijcha.2021.100782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 12/11/2022]
Abstract
The treatment of active cardiac sarcoidosis (CS) usually involves immunosuppressive therapy, with the goal of preventing inflammation-induced scar formation. In most cases, steroids remain the first-line treatment for CS. However, given the side effect profile of their long-term use, steroid-sparing therapies are increasingly used. There are no published randomized trials of steroid-sparing agents in CS. We sought to do a systematic review to evaluate the current published data on the use of non-steroidal treatments in the management of CS. We searched the Cochrane Library, Ovid Medline, Ovid Embase, PubMed, and Web of Science Core Collection databases from inception of database to August 2020 to identify the effectiveness of biological or synthetic disease-modifying antirheumatic agents (s- and bDMARDs). Secondary objectives include safety profile as well as the change in the average corticosteroid dose after treatment initiation. Twenty-three studies were ultimately selected for inclusion which included a total of 480 cases of CS treated with a range of both s- and bDMARDs. In all included studies, sDMARDs and bDMARDs were studied in combination with steroids or as second or higher-line treatments after therapeutic failure or intolerance to corticosteroid use. Methotrexate (MTX) and infliximab (IFX) were the most common synthetic and biologic DMARDs studied respectively, reported in about 35% of the studies reviewed. The use of steroid-sparing agents was associated with a reduction in the maintenance steroid dose used. In conclusion, steroids will remain as the cornerstone of anti-inflammatory management in patients with CS until trials on the use and safety profile of other immunosuppressive agents are completed and published.
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Affiliation(s)
- Cesia Gallegos
- Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Evangelos K Oikonomou
- Yale University School of Medicine, Department of Internal Medicine, New Haven, CT, USA
| | - Alyssa Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Mridu Gulati
- Yale University School of Medicine, Section of Pulmonary, Critical Care & Sleep Medicine, New Haven, CT, USA
| | - Bryan D Young
- Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
| | - Edward J Miller
- Yale University School of Medicine, Section of Cardiovascular Medicine, New Haven, CT, USA
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17
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Boleto G, Vieira M, Desbois AC, Saadoun D, Cacoub P. Emerging Molecular Targets for the Treatment of Refractory Sarcoidosis. Front Med (Lausanne) 2020; 7:594133. [PMID: 33330556 PMCID: PMC7732552 DOI: 10.3389/fmed.2020.594133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/02/2020] [Indexed: 12/19/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown origin that has variable clinical course and can affect nearly any organ. It has a chronic course in about 25% of patients. Corticosteroids (CS) are the cornerstone of therapy but their long-term use is associated with cumulative toxicity. Commonly used CS-sparing agents include methotrexate, cyclophosphamide, azathioprine, and mycophenolate mofetil. Twenty to forty percentage of sarcoidosis patients are refractory to these therapies or develop severe adverse events. Therefore, additional and targeted CS-sparing agents are needed for chronic sarcoidosis. Macrophage activation, interferon response, and formation of the granuloma are mainly mediated by T helper-1 responses. Different pro-inflammatory cytokines such as interleukin (IL)-8, IL-12, IL-6, and tumor necrosis factor-alpha (TNF-α) have been shown to be highly expressed in sarcoidosis-affected tissues. As a result of increased production of these cytokines, Janus kinase-signal transducer and activator of transcription (JAK-STAT) signaling is constitutively active in sarcoidosis. Several studies of biological agents that target TNF-α have reported their efficacy and appear today as a second line option in refractory sarcoidosis. Some case series report a positive effect of tocilizumab an anti-IL-6 monoclonal antibody in this setting. More recently, JAK inhibition appears as a new promising strategy. This review highlights key advances on the management of chronic refractory sarcoidosis. Novel therapeutic strategies and treatment agents to manage the disease are described.
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Affiliation(s)
- Gonçalo Boleto
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Bordeaux, France
| | - Matheus Vieira
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Bordeaux, France
| | - Anne Claire Desbois
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Bordeaux, France.,Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France
| | - David Saadoun
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Bordeaux, France.,Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France
| | - Patrice Cacoub
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France.,Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose, Bordeaux, France.,Sorbonne Université, UPMC Univ Paris 06, UMR 7211, Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France.,INSERM, UMR_S 959, Paris, France.,CNRS, FRE3632, Paris, France
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18
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Bigot W, Chapelon-Abric C, Mangin O, Champion K, Mouly S, Cacoub P, Sene D. Évaluation du cyclophosphamide au cours de la neuro-sarcoïdose : étude rétrospective chez 32 patients. Rev Med Interne 2020. [DOI: 10.1016/j.revmed.2020.10.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 232] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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20
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Abstract
BACKGROUND Prognostic factors are lacking in cardiac sarcoidosis (CS), and the effects of immunosuppressive treatments are unclear. OBJECTIVES To identify prognostic factors and to assess the effects of immunosuppressive drugs on relapse risk in patients presenting with CS. METHODS From a cohort of 157 patients with CS with a median follow-up of 7 years, we analysed all cardiac and extra-cardiac data and treatments, and assessed relapse-free and overall survival. RESULTS The 10-year survival rate was 90% (95% CI, 84-96). Baseline factors associated with mortality were the presence of high degree atrioventricular block (HR, 5.56, 95% CI 1.7-18.2, p = 0.005), left ventricular ejection fraction below 40% (HR, 4.88, 95% CI 1.26-18.9, p = 0.022), hypertension (HR, 4.79, 95% CI 1.06-21.7, p = 0.042), abnormal pulmonary function test (HR, 3.27, 95% CI 1.07-10.0, p = 0.038), areas of late gadolinium enhancement on cardiac magnetic resonance (HR, 2.26, 95% CI 0.25-20.4, p = 0.003), and older age (HR per 10 years 1.69, 95% CI 1.13-2.52, p = 0.01). The 10-year relapse-free survival rate for cardiac relapses was 53% (95% CI, 44-63). Baseline factors that were independently associated with cardiac relapse were kidney involvement (HR, 3.35, 95% CI 1.39-8.07, p = 0.007), wall motion abnormalities (HR, 2.30, 95% CI 1.22-4.32, p = 0.010), and left heart failure (HR 2.23, 95% CI 1.12-4.45, p = 0.023). After adjustment for cardiac involvement severity, treatment with intravenous cyclophosphamide was associated with a lower risk of cardiac relapse (HR 0.16, 95% CI 0.033-0.78, p = 0.024). CONCLUSIONS Our study identifies putative factors affecting morbidity and mortality in cardiac sarcoidosis patients. Intravenous cyclophosphamide is associated with lower relapse rates.
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Abstract
Approximately 5% of patients with sarcoidosis will have clinically manifest cardiac involvement presenting with one or more of ventricular arrhythmias, conduction abnormalities, and heart failure. It is estimated that another 20 to 25% of pulmonary/systemic sarcoidosis patients have asymptomatic cardiac involvement (clinically silent disease). Cardiac presentations can be the first (and/or an unrecognized) manifestation of sarcoidosis in a variety of circumstances. Immunosuppression therapy (usually with corticosteroids) has been suggested for the treatment of clinically manifest cardiac sarcoidosis (CS) despite minimal data supporting it. Positron emission tomography imaging is often used to detect active disease and guide immunosuppression. Patients with clinically manifest disease often need device therapy, typically with implantable cardioverter defibrillators (ICDs). The extent of left ventricular dysfunction seems to be the most important predictor of prognosis among patients with clinically manifest CS. In the current era of earlier diagnosis, modern heart failure treatment, and use of ICD therapy, the prognosis from CS is much improved. In a recent Finnish nationwide study, 10-year cardiac survival was 92.5% in 102 patients.
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Affiliation(s)
- David H Birnie
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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23
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Ghafari C, Vandergheynst F, Parent E, Tanaka K, Carlier S. Exercise-induced torsades de pointes as an unusual presentation of cardiac sarcoidosis: A case report and review of literature. World J Cardiol 2020; 12:291-302. [PMID: 32774781 PMCID: PMC7383351 DOI: 10.4330/wjc.v12.i6.291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/26/2020] [Accepted: 05/17/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Sarcoidosis is a rare multisystem disease characterized histologically by non-caseating granuloma formation in the affected organ. While cardiac sarcoidosis is found on autopsy in up to 25% of sarcoidosis cases, it is still underdiagnosed and is associated with a poor prognosis. Although the etiology of sarcoidosis remains unclear, an antigen triggered exaggerated immune response has been hypothesized. Early detection and prompt management of cardiac sarcoidosis remains pivotal.
CASE SUMMARY A 60-year-old female, with pulmonary sarcoidosis in remission, presented to the cardiology outpatient clinic for evaluation of weeks-long dyspnea on moderate exertion (New York Heart Association class II) that was relieved by rest. Submaximal exercise stress test showed multifocal ventricular extrasystoles, followed by a self-limiting torsades de pointes. Cardiac magnetic resonance imaging showed nondilated and normotrophic left ventricle with basoseptal and mid-septal dyskinesis. The magnetic resonance imaging-derived left ventricular ejection fraction was 45%. Delayed enhancement showed patchy transmural fibrosis of the septum and hyperenhancement of the papillary muscles, all in favor of extensive cardiac involvement of sarcoidosis. A double-chamber implantable cardiac defibrillator was implanted, and methylprednisolone (12 mg/d) and methotrexate (12.5 mg/wk) treatment was initiated. Follow-up and implantable cardiac defibrillator interrogation showed episodes of asymptomatic nonsustained ventricular tachycardia and an asymptomatic episode of nonsustained ventricular tachycardia ending by the first antitachycardia pacing run.
CONCLUSION Along an extensive review of the literature, this unusual case report highlights the importance of early detection of cardiac involvement of sarcoidosis, in order to avoid potential complications and increase survival.
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Affiliation(s)
- Chadi Ghafari
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, Université de Mons, Mons 7000, Belgium
| | - Frédéric Vandergheynst
- Department of Internal Medicine, Cliniques Universitaires de Bruxelles - Erasme, Bruxelles 1070, Belgium
| | - Emmanuel Parent
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
| | - Kaoru Tanaka
- Department of Cardiology, Universitair Ziekenhuis Brussels, Jette 1090, Belgium
| | - Stéphane Carlier
- Department of Cardiology, Centre Hospitalier Universitaire Ambroise Paré, Mons 7000, Belgium
- Department of Cardiology, Université de Mons, Mons 7000, Belgium
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Abstract
PURPOSE OF REVIEW To describe the current knowledge on indications for sarcoidosis treatment. RECENT FINDINGS Despite the lack of evidence-based recommendations, the sarcoidosis community has adopted the concept of starting systemic anti-inflammatory treatment because of potential danger (risk of severe dysfunction on major organs or death) or unacceptable impaired quality of life (QoL). On the contrary, while QoL and functionality are patients' priorities, few studies have evaluated treatment effect on patient-reported outcomes. The awareness of long-term corticosteroids toxicities and consequences on QoL and the emergence of novel drugs have changed therapeutic management. Second-line therapy, mainly methotrexate and azathioprine, are indicated for corticosteroids sparing or corticosteroids-resistant sarcoidosis. TNF-α inhibitors are a useful third-line therapy in chronic refractory disease. In addition to organ-targeted treatment, efforts should also be taken for treating nonorgan-specific symptoms, such as physical training for fatigue, and various disease complications. SUMMARY Clinicians should offer a tailored treatment for each patient and ensure a holistic multidisciplinary approach, including pharmacological and nonpharmacological interventions. Patient-centered communication is critical to drive shared decisions, in particular for the tricky situation of isolated impaired QoL as the unique therapeutic indication. Once treatment is decided, clinicians should define a clear therapeutic plan, including goals and instruments to assess response.
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25
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El Jammal T, Jamilloux Y, Gerfaud-Valentin M, Valeyre D, Sève P. Refractory Sarcoidosis: A Review. Ther Clin Risk Manag 2020; 16:323-345. [PMID: 32368072 PMCID: PMC7173950 DOI: 10.2147/tcrm.s192922] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 03/22/2020] [Indexed: 12/18/2022] Open
Abstract
Sarcoidosis is a multi-system disease of unknown etiology characterized by granuloma formation in various organs (especially lung and mediastinohilar lymph nodes). In more than half of patients, the disease resolves spontaneously. When indicated, it usually responds to corticosteroids, the first-line treatment, but some patients may not respond or tolerate them. An absence of treatment response is rare and urges for verifying the absence of a diagnosis error, the good adherence of the treatment, the presence of active lesions susceptible to respond since fibrotic lesions are irreversible. That is when second-line treatments, immunosuppressants (methotrexate, leflunomide, azathioprine, mycophenolate mofetil, hydroxychloroquine), should be considered. Methotrexate is the only first-line immunosuppressant validated by a randomized controlled trial. Refractory sarcoidosis is not yet a well-defined condition, but it remains a real challenge for the physicians. Herein, we considered refractory sarcoidosis as a disease in which second-line treatments are not sufficient to achieve satisfying disease control or satisfying corticosteroids tapering. Tumor necrosis alpha inhibitors, third-line treatments, have been validated through randomized controlled trials. There are currently no guidelines or recommendations regarding refractory sarcoidosis. Moreover, criteria defining non-response to treatment need to be clearly specified. The delay to achieve response to organ involvement and drugs also should be defined. In the past ten years, the efficacy of several immunosuppressants beforehand used in other autoimmune or inflammatory diseases was reported in refractory cases series. Among them, anti-CD20 antibodies (rituximab), repository corticotrophin injection, and anti-JAK therapy anti-interleukin-6 receptor monoclonal antibody (tocilizumab) were the main reported. Unfortunately, no clinical trial is available to validate their use in the case of sarcoidosis. Currently, other immunosuppressants such as JAK inhibitors are on trial to assess their efficacy in sarcoidosis. In this review, we propose to summarize the state of the art regarding the use of immunosuppressants and their management in the case of refractory or multidrug-resistant sarcoidosis.
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Affiliation(s)
- Thomas El Jammal
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
| | | | - Dominique Valeyre
- Department of Pneumology, Assistance Publique - Hôpitaux de Paris, Hôpital Avicenne et Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - Pascal Sève
- Department of Internal Medicine, Lyon University Hospital, Lyon, France
- Hospices Civils de Lyon, Pôle IMER, Lyon, F-69003, France, University Claude Bernard Lyon 1, HESPER EA 7425, LyonF-69008, France
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26
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Rosenthal DG, Parwani P, Murray TO, Petek BJ, Benn BS, De Marco T, Gerstenfeld EP, Janmohamed M, Klein L, Lee BK, Moss JD, Scheinman MM, Hsia HH, Selby V, Koth LL, Pampaloni MH, Zikherman J, Vedantham V. Long-Term Corticosteroid-Sparing Immunosuppression for Cardiac Sarcoidosis. J Am Heart Assoc 2019; 8:e010952. [PMID: 31538835 PMCID: PMC6818011 DOI: 10.1161/jaha.118.010952] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background Long‐term corticosteroid therapy is the standard of care for treatment of cardiac sarcoidosis (CS). The efficacy of long‐term corticosteroid‐sparing immunosuppression in CS is unknown. The goal of this study was to assess the efficacy of methotrexate with or without adalimumab for long‐term disease suppression in CS, and to assess recurrence and adverse event rates after immunosuppression discontinuation. Methods and Results Retrospective chart review identified treatment‐naive CS patients at a single academic medical center who received corticosteroid‐sparing maintenance therapy. Demographics, cardiac uptake of 18‐fluorodeoxyglucose, and adverse cardiac events were compared before and during treatment and between those with persistent or interrupted immunosuppression. Twenty‐eight CS patients were followed for a mean 4.1 (SD 1.5) years. Twenty‐five patients received 4 to 8 weeks of high‐dose prednisone (>30 mg/day), followed by taper and maintenance therapy with methotrexate±low‐dose prednisone (low‐dose prednisone, <10 mg/day). Adalimumab was added in 19 patients with persistently active CS or in those with intolerance to methotrexate. Methotrexate±low‐dose prednisone resulted in initial reduction (88%) or elimination (60%) of 18‐fluorodeoxyglucose uptake, and patients receiving adalimumab‐containing regimens experienced improved (84%) or resolved (63%) 18‐fluorodeoxyglucose uptake. Radiologic relapse occurred in 8 of 9 patients after immunosuppression cessation, 4 patients on methotrexate‐containing regimens, and in no patients on adalimumab‐containing regimens. Conclusions Corticosteroid‐sparing regimens containing methotrexate with or without adalimumab is an effective maintenance therapy in patients after an initial response is confirmed. Disease recurrence in patients on and off immunosuppression support need for ongoing radiologic surveillance regardless of immunosuppression regimen.
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Affiliation(s)
- David G Rosenthal
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Purvi Parwani
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Tyler O Murray
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Bradley J Petek
- Department of Medicine Massachusetts General Hospital Boston MA
| | - Bryan S Benn
- Division of Pulmonary and Critical Care Department of Medicine University of California, San Francisco San Francisco CA
| | - Teresa De Marco
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Edward P Gerstenfeld
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Munir Janmohamed
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Liviu Klein
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Byron K Lee
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Joshua D Moss
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Melvin M Scheinman
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Henry H Hsia
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Van Selby
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
| | - Laura L Koth
- Division of Pulmonary and Critical Care Department of Medicine University of California, San Francisco San Francisco CA
| | - Miguel H Pampaloni
- Division of Nuclear Medicine Department of Radiology University of California, San Francisco San Francisco CA
| | - Julie Zikherman
- Division of Rheumatology Department of Medicine University of California, San Francisco San Francisco CA
| | - Vasanth Vedantham
- Division of Cardiology Department of Medicine University of California, San Francisco San Francisco CA
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Abstract
PURPOSE OF REVIEW Advanced sarcoidosis is an important cause of morbidity and mortality in sarcoidosis. Over the past few years, several studies have been published clarifying the prevalence and severity of this condition. RECENT FINDINGS Pulmonary involvement is the most common form of sarcoidosis. Increased morbidity and significant mortality is encountered in advanced lung disease. Although many sarcoidosis patients with pulmonary fibrosis have a normal life expectancy, at least 20% develop progression and may die from this complication. Sarcoidosis-associated pulmonary hypertension (SAPH) is an independent cause of death in advanced pulmonary sarcoidosis. Two large multicenter registries and a large single-center report provide more details regarding presentation and outcome of SAPH. Advanced neurologic disease is associated with significant morbidity, but not much mortality. Two large retrospective reviews demonstrated the effectiveness of infliximab in treating advanced neurosarcoidosis. Advanced cardiac sarcoidosis can lead to mortality. SUMMARY Advanced sarcoidosis is associated with significant morbidity and some mortality. Up to a quarter of all sarcoidosis patients have one or more forms of advanced disease. These patients require closer monitoring and often multiples treatments.
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Affiliation(s)
- Robert P Baughman
- Department of Medicine, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
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28
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Ekström K, Lehtonen J, Nordenswan HK, Mäyränpää MI, Räisänen-Sokolowski A, Kandolin R, Simonen P, Pietilä-Effati P, Alatalo A, Utriainen S, Rissanen TT, Haataja P, Kokkonen J, Vihinen T, Miettinen H, Kaikkonen K, Kerola T, Kupari M. Sudden death in cardiac sarcoidosis: an analysis of nationwide clinical and cause-of-death registries. Eur Heart J 2019; 40:3121-3128. [DOI: 10.1093/eurheartj/ehz428] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 03/17/2019] [Accepted: 05/30/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Aims
The present study was done to assess the role of sudden cardiac death (SCD) among the presenting manifestations of and fatalities from cardiac sarcoidosis (CS).
Methods and results
We analysed altogether 351 cases of CS presenting from year 1998 through 2015 in Finland. There were 262 patients with a clinical diagnosis and treatment of CS, 27 patients with an initial lifetime diagnosis of giant cell myocarditis that was later converted to CS, and 62 cases detected at autopsy and identified by screening >820 000 death certificates from the national cause-of-death registry. The total case series comprised 253 females and 98 males aged on average 52 years at presentation. High-grade atrioventricular block was the most common first sign of CS (n = 147, 42%) followed by heart failure (n = 58, 17%), unexpected fatal (n = 38) or aborted (n = 12) SCD (14%), and sustained ventricular tachycardia (n = 48, 14%). Severe coronary artery disease was found at autopsy concomitant with CS in four of the 38 cases presenting with fatal SCD. Of all deaths recorded till the end of 2015, 64% (n = 54/84) were unexpected SCDs from CS that had either been silent during life or defied all attempts at diagnosis. The Kaplan–Meier estimate (95% CI) of survival from symptom onset was 85% (80–90%) at 5 years and 76% (68–84%) at 10 years.
Conclusion
Together fatal and aborted SCD constitute 14% of the presenting manifestations of CS. Nearly two-thirds of all fatalities from CS are caused by undiagnosed granulomas in the heart.
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Affiliation(s)
- Kaj Ekström
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
| | - Hanna-Kaisa Nordenswan
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
| | - Mikko I Mäyränpää
- Pathology, Helsinki University and Helsinki University Hospital, Haartmaninkatu 3, Helsinki, Finland
| | - Anne Räisänen-Sokolowski
- Pathology, Helsinki University and Helsinki University Hospital, Haartmaninkatu 3, Helsinki, Finland
| | - Riina Kandolin
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
| | - Piia Simonen
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
| | - Päivi Pietilä-Effati
- Department of Cardiology, Vaasa Central Hospital, Hietalahdenkatu 2-4, Vaasa, Finland
| | - Aleksi Alatalo
- Interventional Cardiac Unit, The Hospital District of South Ostrobothnia, Seinäjoki Central Hospital, Hanneksenrinne 7, Seinäjoki, Finland
| | - Seppo Utriainen
- Department of Internal Medicine, South Karelia Central Hospital, Valto Käkelän katu 1, 53130 Lappeenranta, Finland
| | - Tuomas T Rissanen
- Heart Center, North Karelia Central Hospital, Tikkamäentie 16, Joensuu, Finland
| | - Petri Haataja
- Tays Heart Hospital, Department of Cardiology, Ensitie 4, 33560 Tampere, Finland
| | - Jorma Kokkonen
- Department of Internal Medicine, Central Finland Central Hospital, Keskussairaalantie 19, Jyväskylä, Finland
| | - Tapani Vihinen
- Heart Center, Turku University Hospital and University of Turku, Hämeentie 11, Turku, Finland
| | - Heikki Miettinen
- Heart Center, Kuopio University Hospital, Puijonlaaksontie 2, Kuopio, Finland
| | - Kari Kaikkonen
- Research Unit of Internal Medicine, University Hospital of Oulu and University of Oulu, Kajaanintie 50, Oulu, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Keskussairaalankatu 7, Lahti, Finland
| | - Markku Kupari
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Stenbäckinkatu 9, Helsinki, Finland
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 186] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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30
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Current management of sarcoidosis I: pulmonary, cardiac, and neurologic manifestations. Curr Opin Rheumatol 2019; 30:243-248. [PMID: 29389828 DOI: 10.1097/bor.0000000000000489] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Sarcoidosis is a systemic disease characterized by noncaseating granulomatous inflammation of multiple organ systems. Pulmonary, cardiac, and neurologic involvements have the worst prognosis. Current recommendations for the therapeutic management and follow-up of sarcoidosis involving these critical organs will be reviewed. RECENT FINDINGS In those sarcoidosis patients requiring immunosuppressive therapy, corticosteroids are used first at varying doses depending on the presenting manifestation. Patients with symptomatic pulmonary, cardiac, or neurologic involvement will be maintained on corticosteroids for at least a year. Many require a second immunosuppressive agent with methotrexate used most commonly. Anti-tumor necrosis factor agents, especially infliximab, are effective and recommendations for their use have been proposed. SUMMARY Evidence-based treatment guidelines do not exist for most sarcoidosis clinical manifestations. Therefore, clinical care of these patients must rely on expert opinion. Patients are best served by a multidisciplinary approach to their care. Future research to identify environmental triggers, genetic associations, biomarkers for treatment response, and where to position new steroid-sparing immunosuppressive agents is warranted.
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31
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Ballul T, Borie R, Crestani B, Daugas E, Descamps V, Dieude P, Dossier A, Extramiana F, van Gysel D, Papo T, Sacre K. Treatment of cardiac sarcoidosis: A comparative study of steroids and steroids plus immunosuppressive drugs. Int J Cardiol 2018; 276:208-211. [PMID: 30527995 DOI: 10.1016/j.ijcard.2018.11.131] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/06/2018] [Accepted: 11/28/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND We aimed to compare the efficacy of steroids alone or associated with immunosuppressive drugs for the prevention of relapse in cardiac sarcoidosis (CS). METHODS In this monocentric multidisciplinary retrospective single center study, all consecutive patients with histologically proven sarcoidosis hospitalized from January 2012 to December 2016 were considered. All patients with symptomatic CS were studied. Patients received steroids or steroids plus immunosuppressive drugs (IS) for CS treatment at diagnosis. The efficacy of each treatment strategy (steroids vs steroids + IS) was assessed by the cardiac relapse rate over follow up. RESULTS 326 consecutive patients with histologically proven sarcoidosis were screened. Among them, 36 (11%) had symptomatic CS (20 (55.5%) men, median age at diagnosis 48.5 [22.8-76]). Twenty-four patients received steroids and 12 received steroids + IS (azathioprine n = 5, methotrexate n = 5, cyclophosphamide n = 2) at CS diagnosis. Over a median follow up of 3.6 [1-15.2] years, 13 (36.1%) patients suffered a cardiac relapse including reduced left ventricular ejection fraction (LVEF, n = 4), third degree heart block (n = 2), atrio-ventricular (n = 1) or ventricular (n = 1) tachycardia and sudden cardiac death (n = 1). Except for a higher frequency of black patients in patients receiving IS, CS features at diagnosis and median time to relapse did not significantly differ between patients who did or did not receive IS. Relapse rate was 45.8% in the steroids group versus 16.7% in the steroids + IS group (p = 0.048). CONCLUSIONS In cardiac sarcoidosis, the combination of steroids with immunosuppressive drugs might reduce the risk of cardiac relapse, as compared to steroids alone.
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Affiliation(s)
- Thomas Ballul
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Raphael Borie
- Département de Pneumologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
| | - Bruno Crestani
- Département de Pneumologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
| | - Eric Daugas
- Département de Nephrologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
| | - Vincent Descamps
- Département de Dermatologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Philippe Dieude
- Département de Rhumatologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France
| | - Antoine Dossier
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Fabrice Extramiana
- Département de Cardiologie, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Damien van Gysel
- Département d'Information Médicale, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Thomas Papo
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France; INSERM U1149, Paris, France
| | - Karim Sacre
- Département de Médecine Interne, Hôpital Bichat, Université Paris Diderot, PRES Sorbonne Paris Cité, Assistance Publique Hôpitaux de Paris, Paris, France; Département Hospitalo-Universitaire FIRE (Fibrosis, Inflammation and Remodelling in Renal and Respiratory Diseases), Paris, France; INSERM U1149, Paris, France.
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