1
|
Pöyhönen P, Lehtonen J, Velikanova D, Simonen P, Uusitalo V, Mälkönen H, Nordenswan HK, Vihinen T, Kaikkonen K, Haataja P, Kerola T, Rissanen TT, Vepsäläinen V, Alatalo A, Pietilä-Effati P, Kupari M. 30-Year Trends in the Incidence, Characteristics, and Outcome of Cardiac Sarcoidosis in a Nationwide Cohort. JACC. ADVANCES 2024; 3:101102. [PMID: 39105120 PMCID: PMC11298841 DOI: 10.1016/j.jacadv.2024.101102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 05/17/2024] [Accepted: 06/05/2024] [Indexed: 08/07/2024]
Abstract
Background Cardiac sarcoidosis (CS) is a rare but potentially fatal inflammatory cardiomyopathy. Objectives The authors studied temporal changes in the incidence, characteristics, and outcome of CS. Methods A retrospective analysis was made of a 30-year nationwide cohort of CS. Results The cohort comprised 511 patients with a median age of 52 years and female preponderance (69%). Altogether 77, 166, and 268 cases of CS were diagnosed in years 1988 to 2009, 2010 to 2014, and 2015 to 2019, respectively; the 5-year count of 2015 to 2019 was 134-fold the count of 1990 to 1994 (268/2) and 18-fold the count of 2000 to 2004 (268/15). Prior to 2010, compared with the later periods, CS presented more often with ventricular tachycardia/fibrillation (prevalence 36% vs 19% in 2010-2014 and 11% in 2015-2019, P < 0.001), left ventricular ejection fraction <50% (49%, 35%, and 31%; P = 0.010), and elevation of natriuretic peptides (87%, 57%, and 49%; P < 0.001). On magnetic resonance imaging, late gadolinium enhancement involved a median of 15% (IQR: 11%-22%) of left ventricular mass in studies of 1988 to 2009 (n = 16), 15% (IQR: 9%-22%) in studies of 2010 to 2014 (n = 87), and 11% (IQR: 5%-19%) in studies of 2015 to 2019 (n = 150) (P = 0.031). The respective 5-year incidences of the composite of death, heart transplantation, left ventricular-assisted device implantation, or ventricular tachyarrhythmia were 40% (95% CI: 29%-51%), 32% (95% CI: 25%-39%), and 23% (95% CI: 16%-30%) (P = 0.002). The prognostic trend disappeared after adjustment for differences in the presenting phenotype. Conclusions Diagnoses of incident CS have increased exponentially in Finland. Concurrently, the phenotype has turned milder and prognosis better, suggesting detection of CS at an earlier stage of its course.
Collapse
Affiliation(s)
- Pauli Pöyhönen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Diana Velikanova
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Piia Simonen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Valtteri Uusitalo
- Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Henriikka Mälkönen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Hanna-Kaisa Nordenswan
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | | | - Kari Kaikkonen
- Medical Research Center Oulu, University and University Hospital of Oulu, Oulu, Finland
| | - Petri Haataja
- Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland
| | | | | | | | | | - Markku Kupari
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
2
|
Harper LJ, Farver CF, Yadav R, Culver DA. A framework for exclusion of alternative diagnoses in sarcoidosis. J Autoimmun 2024:103288. [PMID: 39084998 DOI: 10.1016/j.jaut.2024.103288] [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: 04/29/2024] [Revised: 07/02/2024] [Accepted: 07/13/2024] [Indexed: 08/02/2024]
Abstract
Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.
Collapse
Affiliation(s)
- Logan J Harper
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Carol F Farver
- Department of Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Ruchi Yadav
- Imaging Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel A Culver
- Department of Pulmonary and Critical Care Medicine, Integrated Hospital Care Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
3
|
Boczar KE, Park Y, Wiefels C. Can FDG-PET Imaging Identify Cardiac Sarcoidosis Disease Phenotypes? Curr Cardiol Rep 2024:10.1007/s11886-024-02086-7. [PMID: 38990493 DOI: 10.1007/s11886-024-02086-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE OF REVIEW Despite the scarcity of data, most guidelines have advocated for the treatment of cardiac sarcoidosis with corticosteroids. However, there is heterogeneity in disease presentation and response to treatment, which can make treatment challenging. The ability to identify disease phenotypes to allow for tailored therapy is therefore highly desirable. This review will seek to outline the disease phenotypes of cardiac sarcoidosis and the role that FDG-PET imaging can play in identifying these phenotypes to optimize disease diagnosis and treatment management. RECENT FINDINGS FDG PET can identify cardiac sarcoidosis and is being increasingly used to monitor therapeutic response to immunosuppressive therapy, to follow treatment response after discontinuation of corticosteroid therapy, and to evaluate for disease relapse. Modern quantitative techniques using FDG PET imaging may allow for even better phenotypic disease characterization and the ability to track the response to immunosuppression more accurately. FDG PET currently plays an important role in cardiac sarcoidosis diagnosis. However, it also affords us the opportunity to offer insights into cardiac sarcoidosis disease phenotypes to better understand the underlying disease process and in the future may allows us to tailor therapies accordingly.
Collapse
Affiliation(s)
- Kevin Emery Boczar
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada.
- School of Epidemiology and Public Health, Department of Medicine, University of Ottawa, Ottawa, Canada.
| | - Yooyhun Park
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Christiane Wiefels
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, ON, Canada
- Division of Nuclear Medicine, Department of Medicine, University of Ottawa, Ottawa, Canada
| |
Collapse
|
4
|
Malhi JK, Ibecheozor C, Chrispin J, Gilotra NA. Diagnostic and management strategies in cardiac sarcoidosis. Int J Cardiol 2024; 403:131853. [PMID: 38373681 DOI: 10.1016/j.ijcard.2024.131853] [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: 10/18/2023] [Revised: 01/11/2024] [Accepted: 02/10/2024] [Indexed: 02/21/2024]
Abstract
Cardiac sarcoidosis (CS) is increasingly recognized in the context of with otherwise unexplained electrical or structural heart disease due to improved diagnostic tools and awareness. Therefore, clinicians require improved understanding of this rare but fatal disease to care for these patients. The cardinal features of CS, include arrhythmias, atrio-ventricular conduction delay and cardiomyopathy. In addition to treatments tailored to these cardiac manifestations, immunosuppression plays a key role in active CS management. However, clinical trial and consensus guidelines are limited to guide the use of immunosuppression in these patients. This review aims to provide a practical overview to the current diagnostic challenges, treatment approach, and future opportunities in the field of CS.
Collapse
Affiliation(s)
- Jasmine K Malhi
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Chukwuka Ibecheozor
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
5
|
Scheel PJ, Cartella I, Murray B, Gilotra NA, Ammirati E. Role of genetics in inflammatory cardiomyopathy. Int J Cardiol 2024; 400:131777. [PMID: 38218248 DOI: 10.1016/j.ijcard.2024.131777] [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: 10/27/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
Traditional cardiomyopathy paradigms segregate inflammatory etiologies from those caused by genetic variants. An identified or presumed trigger is implicated in acute myocarditis or chronic inflammatory cardiomyopathy but growing evidence suggests a significant proportion of patients have an underlying cardiomyopathy-associated genetic variant often even when a clear inflammatory trigger is identified. Recognizing a possible genetic contribution to inflammatory cardiomyopathy may have major downstream implications for both the patient and family. The presenting features of myocarditis (i.e. chest pain, arrhythmia, and/or heart failure) may provide insight into diagnostic considerations. One example is isolated cardiac sarcoidosis, a distinct inflammatory cardiomyopathy that carries diagnostic challenges and clinical overlap; genetic testing has increasingly reclassified cases of isolated cardiac sarcoidosis as genetic cardiomyopathy, notably altering management. On the other side, inflammatory presentations of genetic cardiomyopathies are likewise underappreciated and a growing area of investigation. Inflammation plays an important role in the pathogenesis of several familial cardiomyopathies, especially arrhythmogenic phenotypes. Given these clinical scenarios, and the implications on clinical decision making such as initiation of immunosuppression, sudden cardiac death prevention, and family screening, it is important to recognize when genetics may be playing a role.
Collapse
Affiliation(s)
- Paul J Scheel
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA.
| | - Iside Cartella
- De Gasperis Cardio Center, Transplant Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Brittney Murray
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University, USA
| | - Enrico Ammirati
- De Gasperis Cardio Center, Transplant Center, Niguarda Hospital, Milano, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy.
| |
Collapse
|
6
|
Ribeiro Neto ML, Jellis CL, Cremer PC, Harper LJ, Taimeh Z, Culver DA. Cardiac Sarcoidosis. Clin Chest Med 2024; 45:105-118. [PMID: 38245360 DOI: 10.1016/j.ccm.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Cardiac involvement is a major cause of morbidity and mortality in patients with sarcoidosis. It is important to distinguish between clinical manifest diseases from clinically silent diseases. Advanced cardiac imaging studies are crucial in the diagnostic pathway. In suspected isolated cardiac sarcoidosis, it's key to rule out alternative diagnoses. Therapeutic options can be divided into immunosuppressive agents, guideline-directed medical therapy, antiarrhythmic medications, device/ablation therapy, and heart transplantation.
Collapse
Affiliation(s)
- Manuel L Ribeiro Neto
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA.
| | - Christine L Jellis
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Logan J Harper
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Daniel A Culver
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA
| |
Collapse
|
7
|
Churchill R, Sykora D, Castrichini M, Arment C, Myasoedova E, Elwazir M, Bois J, Young K, Rosenbaum A. Clinical Response to Tumor Necrosis Factor-α Inhibitor Therapy in the Management of Cardiac Sarcoidosis. Am J Cardiol 2023; 205:20-27. [PMID: 37579656 DOI: 10.1016/j.amjcard.2023.07.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/19/2023] [Accepted: 07/26/2023] [Indexed: 08/16/2023]
Abstract
Evidence that tumor necrosis factor-α (TNF-α) inhibitors may benefit patients with cardiac sarcoidosis (CS) is limited to small case series and both imaging and clinical outcomes in this population are not well known. This study aimed to evaluate the disease course of patients with CS treated with either infliximab or adalimumab therapy based on serial 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) imaging and clinical outcomes. An institutional CS research database was queried for patients treated with TNF-α inhibitors between 2016 and 2021. Outcomes included (1) change in mean prednisone dose, (2) FDG-PET improvement, and (3) unplanned hospitalizations, advanced heart failure therapies, or death. Our query yielded 31 patients with CS. A total of 13 patients were on infliximab, 15 patients were on adalimumab, and 3 patients were on adalimumab before transitioning to infliximab. Mean prednisone dose decreased between FDG-PET immediately preceding TNF-α and second after TNF-α FDG-PET (18.6 ± 15.7 mg to 7.7 ± 12.4 mg, p = 0.018). A significant decrease was seen in the mean number of segments demonstrating FDG uptake between most recent pre-TNF-α and first after TNF-α inhibitor FDG-PET (mean segments = 4.2 vs 3.1, p = 0.048). Between earliest pre-TNF-α and first after TNF-α FDG-PET there was a numerical decrease in average myocardial maximum standard uptake values (SUVmax) (4.4 vs 3.1, p = 0.18), and the ratio of SUVmax myocardium:SUVmax blood pool (1.9 vs 1.5, p = 0.26). Within 36 months of initiating TNF-α inhibitor, 4 patients (13%) experienced unplanned cardiovascular hospitalization (median time to hospitalization = 12.1 months). In conclusion, in patients with CS, TNF-α inhibitor therapy is associated with decreased glucocorticoid use, numerical decrease in cardiac FDG uptake, and minimal cardiac morbidity.
Collapse
Affiliation(s)
- Robert Churchill
- Mayo Clinic Alix School of Medicine, Mayo Clinic College of eEdicine and Science, Mayo Clinic, Rochester, Minnesota
| | - Daniel Sykora
- Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Matteo Castrichini
- Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Courtney Arment
- Division of Rheumatology, Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Elena Myasoedova
- Division of Rheumatology, Department of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Mohamed Elwazir
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - John Bois
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Kathleen Young
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Andrew Rosenbaum
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
8
|
Sink J, Joyce C, Liebo MJ, Wilber DJ. Long-Term Outcomes of Cardiac Sarcoid: Prognostic Implications of Isolated Cardiac Involvement and Impact of Diagnostic Delays. J Am Heart Assoc 2023; 12:e028342. [PMID: 37750587 PMCID: PMC10727252 DOI: 10.1161/jaha.122.028342] [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: 09/29/2022] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
Background Isolated cardiac sarcoid (iCS) is reported to have more severe clinical presentation and greater risk of adverse events compared with cardiac sarcoid (CS) with extracardiac involvement (nonisolated CS). Delays in diagnosing specific organ involvement may play a role in these described differences. Methods and Results A retrospective observational study of patients with CS over a 20-year period was conducted. Objective evidence of organ involvement and time of onset based on consensus criteria were identified. CS was confirmed by histology in all patients from myocardium only (iCS) or extracardiac tissue (nonisolated CS). The primary end point was a composite of mortality, orthotopic heart transplant, and durable left ventricular assist device implantation. CS was isolated in 9 of 50 patients (18%). Among baseline characteristics, iCS and nonisolated CS differed significantly only in the frequency of sustained ventricular tachycardia at presentation (78% versus 37%; P=0.03) and delay in CS diagnosis >6 months (67% versus 5%; P<0.01). A nonsignificant trend toward lower left ventricular ejection fraction and more frequent heart failure in iCS was observed. Over a median follow-up of 9.7 years (95% CI, 6.8-10.8), 18 patients reached the primary end point (13 deaths, 2 orthotopic heart transplants, and 3 durable left ventricular assist device implantations). The 1-, 5-, and 10-year event-free survival rates were 96% (95% CI, 85%-99%), 79% (95% CI, 64%-88%), and 58% (95% CI, 40%-73%), respectively, without differences between groups. There were no significant predictors of the primary end point, including delayed CS diagnosis. Conclusions Long-term outcomes were similar between iCS and nonisolated CS in patients with histologically documented sarcoid. Diagnostic delays may contribute to differences in the dominant clinical presentation, despite similar outcomes.
Collapse
Affiliation(s)
- Joshua Sink
- Loyola University Chicago Stritch School of MedicineMaywoodILUSA
- Present address:
Department of MedicineNorthwestern UniversityChicagoILUSA
| | - Cara Joyce
- Department of MedicineLoyola University of Chicago Stritch School of MedicineMaywoodILUSA
| | - Max J. Liebo
- Section of Advanced Heart Failure, Division of Cardiology, Department of MedicineLoyola University Chicago Stritch School of MedicineMaywoodILUSA
| | - David J. Wilber
- Department of MedicineLoyola University of Chicago Stritch School of MedicineMaywoodILUSA
| |
Collapse
|
9
|
Gazitt T, Kharouf F, Feld J, Haddad A, Hijazi N, Kibari A, Fuks A, Sabo E, Mor M, Peleg H, Asleh R, Zisman D. Real-Life Utilization of Criteria Guidelines for Diagnosis of Cardiac Sarcoidosis (CS). J Clin Med 2023; 12:5278. [PMID: 37629319 PMCID: PMC10455608 DOI: 10.3390/jcm12165278] [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: 06/14/2023] [Revised: 07/10/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Despite the increasing recognition of cardiac involvement in systemic sarcoidosis, the diagnosis of cardiac sarcoidosis (CS) remains challenging. Our aim is to present a comprehensive, retrospective case series of CS patients, focusing on the current diagnostic guidelines and management of this life-threatening condition. In our case series, patient data were collected retrospectively, including hospital admission records and rheumatology and cardiology clinic visit notes, detailing demographic, clinical, laboratory, pathology, and imaging studies, as well as cardiac devices and prescribed medications. Cases were divided into definite and probable CS based on the 2014 Heart Rhythm Society guidelines as well as presumed CS based on imaging criteria and clinical findings. Overall, 19 CS patients were included, 17 of whom were diagnosed with probable or presumed CS based on cardiac magnetic resonance imaging (CMR) and/or cardiac positron emission tomography using 18F-Fluorodeoxyglucose (PET-FDG) without supporting endomyocardial biopsy (EMB). The majority of CS patients were male (53%), with a mean age of 52.9 ± 11.8, with CS being the initial manifestation of sarcoidosis in 63% of cases. Most patients presented with high-grade AVB (63%), followed by heart failure (42%) and ventricular tachyarrhythmia (VT) (26%). This case series highlights the significance of utilizing updated diagnostic criteria relying on CMR and PET-FDG given that cardiac involvement can be the initial manifestation of systemic sarcoidosis, requiring prompt diagnosis and treatment to prevent morbidity and mortality.
Collapse
Affiliation(s)
- Tal Gazitt
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
- Division of Rheumatology, University of Washington Medical Center, Seattle, WA 98195-6428, USA
| | - Fadi Kharouf
- Rheumatology Unit, Hadassah Medical Center, Jerusalem 9112001, Israel
- Faculty of Medicine, Hadassah Medical Center, Jerusalem 9112001, Israel;
| | - Joy Feld
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 3200003, Israel
| | - Amir Haddad
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
| | - Nizar Hijazi
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
| | - Adi Kibari
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
- Internal Medicine B, Carmel Medical Center, Haifa 3436212, Israel
| | - Alexander Fuks
- Department of Cardiology, Carmel Medical Center, Haifa 3436212, Israel
| | - Edmond Sabo
- Department of Pathology, Carmel Medical Center, Haifa 3436212, Israel
| | - Maya Mor
- Department of Radiology, Carmel Medical Center, Haifa 3436212, Israel
| | - Hagit Peleg
- Rheumatology Unit, Hadassah Medical Center, Jerusalem 9112001, Israel
- Faculty of Medicine, Hadassah Medical Center, Jerusalem 9112001, Israel;
| | - Rabea Asleh
- Faculty of Medicine, Hadassah Medical Center, Jerusalem 9112001, Israel;
- Department of Cardiology, Hadassah Medical Center, Jerusalem 9112001, Israel
| | - Devy Zisman
- Rheumatology Unit, Carmel Medical Center, Haifa 3436212, Israel (D.Z.)
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa 3200003, Israel
| |
Collapse
|
10
|
Kurashima S, Kitai T, Xanthopoulos A, Skoularigis J, Triposkiadis F, Izumi C. Diagnosis of cardiac sarcoidosis: histological evidence vs. imaging. Expert Rev Cardiovasc Ther 2023; 21:693-702. [PMID: 37776232 DOI: 10.1080/14779072.2023.2266367] [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: 04/01/2023] [Accepted: 09/29/2023] [Indexed: 10/02/2023]
Abstract
INTRODUCTION The prognosis for cardiac sarcoidosis (CS) remains unfavorable. Although early and accurate diagnosis is crucial, the low detection rate of endomyocardial biopsy makes accurate diagnosis challenging. AREAS COVERED The Heart Rhythm Society (HRS) consensus statement and the Japanese Circulation Society (JCS) guidelines are two major diagnostic criteria for the diagnosis of CS. While the requirement of positive histology for the diagnosis in the HRS criteria can result in overlooked cases, the JCS guidelines advocate for a group of 'clinical' diagnoses based on advanced imaging, including cardiovascular magnetic resonance and 18F-fluorodeoxyglucose positron emission tomography, which do not require histological evidence. Recent studies have supported the usefulness of clinical diagnosis of CS. However, other evidence suggests that clinical CS may sometimes be inaccurate. This article describes the advantages and disadvantages of the current diagnostic criteria for CS, and typical imaging and clinical courses. EXPERT OPINION The diagnosis of clinical CS has been made possible by recent developments in multimodality imaging. However, it is still crucial to look for histological signs of sarcoidosis in other organs in addition to the endomyocardium. Additionally, phenotyping based on clinical manifestations such as heart failure, conduction abnormality or ventricular arrhythmia, and extracardiac abnormalities is clinically significant.
Collapse
Affiliation(s)
- Shinichi Kurashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - John Skoularigis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | | | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| |
Collapse
|
11
|
Yoshida S, Nakata T, Naya M, Momose M, Taniguchi Y, Fukushima Y, Moroi M, Okizaki A, Hashimoto A, Kiko T, Hida S, Takehana K, Nakajima K. Prognostic Implications of Sarcoidosis Granulomas - Insights From the Multicenter Registry, the Japanese Cardiac Sarcoidosis Prognostic Study. Circ Rep 2023; 5:252-259. [PMID: 37305793 PMCID: PMC10247353 DOI: 10.1253/circrep.cr-23-0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 04/04/2023] [Indexed: 06/13/2023] Open
Abstract
Background: Definitions of cardiac sarcoidosis (CS) differ among guidelines. Any systemic histological finding of CS is essential for the diagnosis of CS in the 2014 Heart Rhythm Society statement, but not necessary in the Japanese Circulation Society 2016 guidelines. This study aimed to reveal the differences in outcomes by comparing 2 groups, namely CS patients with or without systemic histologically proven granuloma. Methods and Results: This study retrospectively included 231 consecutive patients with CS. CS with granulomas in ≥1 organs was diagnosed in 131 patients (Group G), whereas CS without any granulomas was diagnosed in the remaining 100 patients (Group NG). Left ventricular ejection fraction (LVEF) was significantly reduced in Group NG compared with Group G (44±13% vs. 50±16%, respectively; P=0.001). However, Kaplan-Meier curves showed that major adverse cardiovascular events (MACE)-free survival outcomes were comparable between the 2 groups (log-rank P=0.167). Univariable analyses showed that significant predictors of MACE were Groups G/NG, histological CS, LVEF, and high B-type natriuretic peptide (BNP) or N-terminal pro BNP concentrations, but none of these was significant in multivariable analyses. Conclusions: Overall risks of MACE were similar between the 2 groups despite different manifestations in cardiac dysfunction. The data not only validate the prognostic value of non-invasive diagnosis of CS, but also show the need for careful observation and therapeutic strategy in patients with CS without any granuloma.
Collapse
Affiliation(s)
- Shohei Yoshida
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Science Kanazawa Japan
| | | | - Masanao Naya
- Department of Cardiology, Hokkaido University Hospital Sapporo Japan
| | - Mitsuru Momose
- Department of Diagnostic Imaging and Nuclear Medicine, Tokyo Woman's Medical University Tokyo Japan
| | - Yasuyo Taniguchi
- Department of General Medicine, Hyogo Harima-Himeji General Hospital Himeji Japan
| | | | - Masao Moroi
- Department of Cardiovascular Medicine, Toho University Ohashi Medical Center Tokyo Japan
| | - Atsutaka Okizaki
- Department of Radiology, Asahikawa Medical University Asahikawa Japan
| | | | - Takatoyo Kiko
- Department of Cardiology, Fukushima Medical University Fukushima Japan
| | - Satoshi Hida
- Department of Cardiology, Tokyo Medical University Tokyo Japan
| | - Kazuya Takehana
- Division of Cardiology, Department of Medicine II, Kansai Medical University Hirakata Japan
| | - Kenichi Nakajima
- Department of Functional Imaging and Artificial Intelligence, Kanazawa University Kanazawa Japan
| |
Collapse
|
12
|
The Mechanism and Natural History of Mitral Regurgitation in Cardiac Sarcoidosis. Am J Cardiol 2023; 191:84-91. [PMID: 36669382 DOI: 10.1016/j.amjcard.2023.01.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 11/28/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023]
Abstract
Cardiac sarcoidosis (CS) is an infl/ammatory cardiomyopathy that can present with mitral regurgitation (MR), but few studies describe the mechanisms and natural history of MR in CS. We queried an institutional registry of 512 patients with CS for moderate or greater MR at diagnosis. Baseline demographic and echocardiography (TTE) data were collected. MR was classified by Carpentier type. Positron emission tomography was analyzed for 2-deoxy-2-[fluorine-18] fluoro-d-glucose (FDG) avidity of anterolateral and posteromedial papillary muscles. Follow-up TTE and positron emission tomography imaging of patients treated with immunosuppression was analyzed for MR severity and FDG avidity changes. Fifty-four patients were identified. Mean left ventricular ejection fraction was 39.3%, effective regurgitant orifice 0.34 cm2, and MR regurgitant volume 46.3 ml. Carpentier type I was the most common MR mechanism (46.3%). Forty-one patients had follow-up TTE (median follow-up 1.7 years, interquartile range 2.6 years). Evaluating preprocedural follow-up TTE only, MR severity was significantly reduced, with 37% of patients showing reduction by at least 1 severity grade (p = 0.04). With postprocedural TTE included, 61% of patients showed alleviation of MR severity with mean decrease in grade - 0.98 (p <0.001). Sixty-eight percent of patients had anterolateral/posteromedial FDG avidity. Papillary muscle FDG avidity resolved in 80% of patients (n = 20, median follow-up 1.6 years, interquartile range 2.5 years). In conclusion, Carpentier type I functional MR is the most common MR mechanism in CS. MR severity and papillary muscle FDG avidity decrease after treatment, and MR resolution is further strengthened by procedural intervention in a minority of patients, suggesting an overall favorable natural history of MR in CS.
Collapse
|
13
|
Okada T, Kawaguchi N, Miyagawa M, Matsuoka M, Tashiro R, Tanabe Y, Kido T, Miyoshi T, Higashi H, Inoue T, Okayama H, Yamaguchi O, Kido T. Clinical features and prognosis of isolated cardiac sarcoidosis diagnosed using new guidelines with dedicated FDG PET/CT. J Nucl Cardiol 2023; 30:280-289. [PMID: 35804283 PMCID: PMC9984349 DOI: 10.1007/s12350-022-03034-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 05/26/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Diagnostic guidelines for isolated cardiac sarcoidosis (iCS) were first proposed in 2016, but there are few reports on the imaging and prognosis of iCS. This study aimed to evaluate the use of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (FDG PET/CT) imaging in predicting iCS prognosis. METHODS AND RESULTS We retrospectively reviewed the clinical and imaging data of 306 consecutive patients with suspected CS who underwent FDG PET/CT with a dedicated preparation protocol and included 82 patients (55 with systemic sarcoidosis including cardiac involvement [sCS], 27 with iCS) in the study. We compared the FDG PET/CT findings between the two groups. We examined the relationship between the CS type and the rate of adverse cardiac events. The iCS group had a significantly lower target-to-background ratio than the sCS group (P = 0.0010). The event-free survival rate was significantly lower in the iCS group than the sCS group (log-rank test, P < 0.0001). iCS was identified as an independent prognostic factor for adverse events (hazard ratio 3.82, P = 0.0059). CONCLUSION iCS was an independent prognostic factor for adverse cardiac events in patients with CS. The clinical diagnosis of iCS based on FDG PET/CT and new guidelines may be important.
Collapse
Affiliation(s)
- Tomohisa Okada
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Naoto Kawaguchi
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Masao Miyagawa
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan.
| | - Marika Matsuoka
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Rami Tashiro
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Yuki Tanabe
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Tomoyuki Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Toru Miyoshi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Haruhiko Higashi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Takeshi Inoue
- Department of Radiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Hideki Okayama
- Department of Cardiology, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Osamu Yamaguchi
- Department of Cardiology, Pulmonology, Hypertension and Nephrology, Ehime University Graduate School of Medicine, Toon, Japan
| | - Teruhito Kido
- Department of Radiology, Ehime University Graduate School of Medicine, Shitsukawa, Toon, Ehime, 791-0295, Japan
| |
Collapse
|
14
|
Abstract
About 5% of sarcoidosis patients develop clinically manifest cardiac features. Cardiac sarcoidosis (CS) typically presents with conduction abnormalities, ventricular arrhythmias and heart failure. Its diagnosis is challenging and requires a substantial degree of clinical suspicion as well as expertise in advanced cardiac imaging. Adverse events, particularly malignant arrhythmias and development of heart failure, are common among CS patients. A timely diagnosis is paramount to ameliorating outcomes for these patients. Despite weak evidence, immunosuppression (primarily with corticosteroids) is generally recommended in the presence of active inflammation in the myocardium. The burden of malignant arrhythmias remains important regardless of treatment, thus leading to the recommended use of an implantable cardioverter defibrillator in most patients with clinically manifest CS.
Collapse
Affiliation(s)
- Alessandro De Bortoli
- Division of Cardiology, University of Ottawa Heart Institute.,Department of Cardiology, Vestfold Hospital Trust
| | - David H Birnie
- Division of Cardiology, University of Ottawa Heart Institute
| |
Collapse
|
15
|
Nordenswan HK, Pöyhönen P, Lehtonen J, Ekström K, Uusitalo V, Niemelä M, Vihinen T, Kaikkonen K, Haataja P, Kerola T, Rissanen TT, Alatalo A, Pietilä-Effati P, Kupari M. Incidence of Sudden Cardiac Death and Life-Threatening Arrhythmias in Clinically Manifest Cardiac Sarcoidosis With and Without Current Indications for an Implantable Cardioverter Defibrillator. Circulation 2022; 146:964-975. [PMID: 36000392 PMCID: PMC9508990 DOI: 10.1161/circulationaha.121.058120] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 07/18/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Cardiac sarcoidosis (CS) predisposes to sudden cardiac death (SCD). Guidelines for implantable cardioverter defibrillators (ICDs) in CS have been issued by the Heart Rhythm Society in 2014 and the American College of Cardiology/American Heart Association/Heart Rhythm Society consortium in 2017. How well they discriminate high from low risk remains unknown. METHODS We analyzed the data of 398 patients with CS detected in Finland from 1988 through 2017. All had clinical cardiac manifestations. Histological diagnosis was myocardial in 193 patients (definite CS) and extracardiac in 205 (probable CS). Patients with and without Class I or IIa ICD indications at presentation were identified, and subsequent occurrences of SCD (fatal or aborted) and sustained ventricular tachycardia were recorded, as were ICD indications emerging first on follow-up. RESULTS Over a median of 4.8 years, 41 patients (10.3%) had fatal (n=8) or aborted (n=33) SCD, and 98 (24.6%) experienced SCD or sustained ventricular tachycardia as the first event. By the Heart Rhythm Society guideline, Class I or IIa ICD indications were present in 339 patients (85%) and absent in 59 (15%), of whom 264 (78%) and 30 (51%), respectively, received an ICD. Cumulative 5-year incidence of SCD was 10.7% (95% CI, 7.4%-15.4%) in patients with ICD indications versus 4.8% (95% CI, 1.2%-19.1%) in those without (χ2=1.834, P=0.176). The corresponding rates of SCD were 13.8% (95% CI, 9.1%-21.0%) versus 6.3% (95% CI, 0.7%-54.0%; χ2=0.814, P=0.367) in definite CS and 7.6% (95% CI, 3.8%-15.1%) versus 3.3% (95% CI, 0.5%-22.9%; χ2=0.680, P=0.410) in probable CS. In multivariable regression analysis, SCD was predicted by definite histological diagnosis (P=0.033) but not by Class I or IIa ICD indications (P=0.210). In patients without ICD indications at presentation, 5-year incidence of SCD, sustained ventricular tachycardia, and emerging Class I or IIa indications was 53% (95% CI, 40%-71%). By the American College of Cardiology/American Heart Association/Heart Rhythm Society guideline, all patients with complete data (n=245) had Class I or IIa indications for ICD implantation. CONCLUSIONS Current ICD guidelines fail to distinguish a truly low-risk group of patients with clinically manifest CS, the 5-year risk of SCD approaching 5% despite absent ICD indications. Further research is needed on prognostic factors, including the role of diagnostic histology. Meanwhile, all patients with CS presenting with clinical cardiac manifestations should be considered for an ICD implantation.
Collapse
MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/epidemiology
- Arrhythmias, Cardiac/therapy
- Death, Sudden, Cardiac/epidemiology
- Death, Sudden, Cardiac/etiology
- Death, Sudden, Cardiac/prevention & control
- Defibrillators, Implantable/adverse effects
- Humans
- Incidence
- Myocarditis/complications
- Risk Factors
- Sarcoidosis/complications
- Sarcoidosis/diagnosis
- Sarcoidosis/epidemiology
- Tachycardia, Ventricular/diagnosis
- Tachycardia, Ventricular/epidemiology
- Tachycardia, Ventricular/therapy
Collapse
Affiliation(s)
- Hanna-Kaisa Nordenswan
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Pauli Pöyhönen
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
- Radiology (P.P., V.U.), Helsinki University Hospital and University of Helsinki, Finland
| | - Jukka Lehtonen
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Kaj Ekström
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
| | - Valtteri Uusitalo
- Radiology (P.P., V.U.), Helsinki University Hospital and University of Helsinki, Finland
- Clinical Physiology and Nuclear Medicine (V.U.), Helsinki University Hospital and University of Helsinki, Finland
| | - Meri Niemelä
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
| | | | - Kari Kaikkonen
- Medical Research Center Oulu, University and University Hospital of Oulu, Finland (K.K.)
| | - Petri Haataja
- Heart Hospital, Tampere University Hospital, Finland (P.H.)
| | - Tuomas Kerola
- Department of Internal Medicine, Päijät-Häme Central Hospital, Lahti, Finland (T.K.)
| | | | - Aleksi Alatalo
- South Ostrobothnia Central Hospital, Seinäjoki, Finland (A.A.)
| | | | - Markku Kupari
- Heart and Lung Center (H.-K.N., P.P., J.L., K.E., M.N., M.K.), Helsinki University Hospital and University of Helsinki, Finland
| |
Collapse
|
16
|
Shabtaie SA, Sehrawat O, Lee JZ, Cha Y, Mulpuru SK, Kowlgi NG, Siontis KC, Rosenbaum AN, Bois JP, AbouEzzeddine OF, Noseworthy PA, Asirvatham SJ, DeSimone CV, Deshmukh AJ. Cardiac Resynchronization Therapy Response in Cardiac Sarcoidosis. J Cardiovasc Electrophysiol 2022; 33:2072-2080. [DOI: 10.1111/jce.15631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 04/25/2022] [Accepted: 05/11/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Samuel A. Shabtaie
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Ojasav Sehrawat
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Justin Z. Lee
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Yong‐Mei Cha
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Siva K. Mulpuru
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Narayan G. Kowlgi
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | | | - Andrew N. Rosenbaum
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - John P. Bois
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Omar F. AbouEzzeddine
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Peter A. Noseworthy
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | - Samuel J. Asirvatham
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| | | | - Abhishek J. Deshmukh
- Department of Cardiovascular MedicineMayo Clinic200 First Street SWRochesterMN55905USA
| |
Collapse
|
17
|
Kitai T, Nabeta T, Naruse Y, Taniguchi T, Yoshioka K, Miyakoshi C, Kurashima S, Miyoshi Y, Tanaka H, Okumura T, Baba Y, Furukawa Y, Matsue Y, Izumi C. Comparisons between biopsy-proven versus clinically diagnosed cardiac sarcoidosis. Heart 2022; 108:1887-1894. [PMID: 35790370 DOI: 10.1136/heartjnl-2022-320932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 06/10/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Diagnosis of cardiac sarcoidosis (CS) without histological evidence remains controversial. This study aimed to compare characteristics and outcomes of histologically proven versus clinically diagnosed cases of CS, which were adjudicated using Heart Rhythm Society or Japanese Circulation Society criteria. METHODS A total of 512 patients with CS (age: 62±11 years, female: 64.3%) enrolled in the multicentre registry were studied. Histologically confirmed patients were classified as 'biopsy-proven CS', while those with the presence of strongly suggestive clinical findings of CS without histological evidence were classified as 'clinical CS'. Primary outcome was a composite of all-cause death, heart failure hospitalisation and ventricular arrhythmia event. RESULTS In total, 314 patients (61.3%) were classified as biopsy-proven CS, while 198 (38.7%) were classified as clinical CS. Patients classified under clinical CS were associated with higher prevalence of left ventricular dysfunction, septal thinning, and positive findings in fluorodeoxyglucose-positron emission tomography or Gallium scintigraphy than those under biopsy-proven CS. During median follow-up of 43.7 (23.3-77.3) months, risk of primary outcome was comparable between the groups (adjusted HR: 1.24, 95% CI: 0.88 to 1.75, p=0.22). Similarly, the risks of primary outcome were comparable between patients with clinical isolated CS who did not have other organ/tissue involvement, and biopsy-proven isolated CS (adjusted HR: 1.23, 95% CI: 0.56 to 2.70, p=0.61). CONCLUSIONS A substantial number of patients were diagnosed with clinical CS without confirmatory biopsy. Considering the worse clinical outcomes irrespective of the histological evidence, the diagnosis of clinical CS is justifiable if imaging findings suggestive of CS are observed.
Collapse
Affiliation(s)
- Takeshi Kitai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan .,Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Takeru Nabeta
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yoshihisa Naruse
- Division of Cardiology, Internal Medicine III, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tatsunori Taniguchi
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - Chisato Miyakoshi
- Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Shinichi Kurashima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yutaro Miyoshi
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan.,Department of Cardiovascular Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Yutaka Furukawa
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Bunkyo-ku, Tokyo, Japan
| | - Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
18
|
Abstract
PURPOSE OF REVIEW Cardiac sarcoidosis (CS) is a potentially fatal condition when unrecognized or not treated adequately. The purpose of this review is to provide new strategies to increase clinical recognition of CS and to present an updated overview of the immunosuppressive treatments using most recent data published in the last 18 months. RECENT FINDINGS CS is an increasingly recognized pathology, and its diagnostic is made 20 times more often in the last two decades. Recent studies have shown that imaging alone usually lacks specificity to distinguish CS from other inflammatory cardiomyopathies. However, imaging can be used to increase significantly diagnostic yield of extracardiac and cardiac biopsy. Recent reviews have also demonstrated that nearly 25% of patients will be refractory to standard treatment with prednisone and that combined treatment with a corticosteroid-sparing agent is often necessary for a period that remains undetermined. SUMMARY CS is a complex pathology that should always require a biopsy attempt to have a histological proven diagnosis before starting immunosuppressive therapy consisting of corticosteroids with or without a corticosteroid-sparing agent.
Collapse
Affiliation(s)
- Sylvain Lemay
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, Quebec, Canada
| | | | | |
Collapse
|
19
|
Elwazir MY, Bois JP, Chareonthaitawee P. Utilization of cardiac imaging in sarcoidosis. Expert Rev Cardiovasc Ther 2022; 20:253-266. [DOI: 10.1080/14779072.2022.2069560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Mohamed Y. Elwazir
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - John P. Bois
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | | |
Collapse
|
20
|
Ammirati E, Bizzi E, Veronese G, Groh M, Van de Heyning CM, Lehtonen J, Pineton de Chambrun M, Cereda A, Picchi C, Trotta L, Moslehi JJ, Brucato A. Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis. Front Med (Lausanne) 2022; 9:838564. [PMID: 35350578 PMCID: PMC8958011 DOI: 10.3389/fmed.2022.838564] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
The field of inflammatory disease of the heart or "cardio-immunology" is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.
Collapse
Affiliation(s)
- Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milano, Italy
| | - Emanuele Bizzi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Giacomo Veronese
- Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Matthieu Groh
- National Reference Center for Hypereosinophilic Syndromes, CEREO, Suresnes, France
- Department of Internal Medicine, Hôpital Foch, Suresnes, France
| | - Caroline M. Van de Heyning
- Department of Cardiology, Antwerp University Hospital, and GENCOR Research Group, Antwerp University, Antwerp, Belgium
| | - Jukka Lehtonen
- Department of Cardiology, Heart and Lung Center, Helsinki University Hospital, Helsinki, Finland
| | - Marc Pineton de Chambrun
- Sorbonne Université, Assistance Publique-Hôpitaux de Paris (APHP), Hôpital La Pitié-Salpêtrière, Service de Médecine Intensive-Réanimation, Paris, France
- Sorbonne Université, APHP, Hôpital de la Pitié-Salpêtrière, Service de Médecine Interne 2, Centre de Référence National Lupus et SAPL et Autres Maladies Auto-immunes et Systémiques Rares, Paris, France
- Sorbonne Université, INSERM, UMRS_1166-ICAN, ICAN, Paris, France
| | - Alberto Cereda
- Cardiovascular Department, Association Socio Sanitary Territorial Santi Paolo e Carlo, Milano, Italy
| | - Chiara Picchi
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Lucia Trotta
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
| | - Javid J. Moslehi
- Section of Cardio-Oncology and Immunology, Division of Cardiology and the Cardiovascular Research Institute, University of California, San Francisco, San Francisco, CA, United States
| | - Antonio Brucato
- Internal Medicine, Fatebenefratelli Hospital, Milano, Italy
- Department of Biomedical and Clinical Sciences “Luigi Sacco, ” Fatebenefratelli Hospital, University of Milano, Milano, Italy
| |
Collapse
|
21
|
Gilotra NA, Griffin JM, Pavlovic N, Houston BA, Chasler J, Goetz C, Chrispin J, Sharp M, Kasper EK, Chen ES, Blankstein R, Cooper LT, Joyce E, Sheikh FH. Sarcoidosis-Related Cardiomyopathy: Current Knowledge, Challenges, and Future Perspectives State-of-the-Art Review. J Card Fail 2021; 28:113-132. [PMID: 34260889 DOI: 10.1016/j.cardfail.2021.06.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 06/21/2021] [Indexed: 12/21/2022]
Abstract
The prevalence of sarcoidosis-related cardiomyopathy is increasing. Sarcoidosis impacts cardiac function through granulomatous infiltration of the heart, resulting in conduction disease, arrhythmia, and/or heart failure. The diagnosis of cardiac sarcoidosis (CS) can be challenging and requires clinician awareness as well as differentiation from overlapping diagnostic phenotypes, such as other forms of myocarditis and arrhythmogenic cardiomyopathy. Clinical manifestations, extracardiac involvement, histopathology, and advanced cardiac imaging can all lend support to a diagnosis of CS. The mainstay of therapy for CS is immunosuppression; however, no prospective clinical trials exist to guide management. Patients may progress to developing advanced heart failure or ventricular arrhythmia, for which ventricular assist device therapies or heart transplantation may be considered. The existing knowledge gaps in CS call for an interdisciplinary approach to both patient care and future investigation to improve mechanistic understanding and therapeutic strategies.
Collapse
Affiliation(s)
- Nisha A Gilotra
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
| | - Jan M Griffin
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Columbia University School of Medicine, New York, New York
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Brian A Houston
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jessica Chasler
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland
| | - Colleen Goetz
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| | - Jonathan Chrispin
- Clinical Cardiac Electrophysiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Michelle Sharp
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward K Kasper
- Advanced Heart Failure/Transplant Cardiology Section, Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Edward S Chen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ron Blankstein
- Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, Florida
| | - Emer Joyce
- Department of Cardiology, Mater Misericordiae University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Farooq H Sheikh
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC
| |
Collapse
|
22
|
Ammirati E, Camici PG, Lehtonen J. Overcoming the low yield of histology for the diagnosis of cardiac sarcoidosis. Int J Cardiol 2021; 337:86-87. [PMID: 34102244 DOI: 10.1016/j.ijcard.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Enrico Ammirati
- Transplant Center and "De Gasperis" Cardio Center, Niguarda Hospital, Milan, Italy.
| | - Paolo G Camici
- San Raffaele Hospital and Vita Salute University, Milan, Italy
| | - Jukka Lehtonen
- Heart and Lung Center, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| |
Collapse
|