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Sharma R, Kouranos V, Cooper LT, Metra M, Ristic A, Heidecker B, Baksi J, Wicks E, Merino JL, Klingel K, Imazio M, de Chillou C, Tschöpe C, Kuchynka P, Petersen SE, McDonagh T, Lüscher T, Filippatos G. Management of cardiac sarcoidosis. Eur Heart J 2024; 45:2697-2726. [PMID: 38923509 DOI: 10.1093/eurheartj/ehae356] [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: 03/20/2024] [Revised: 05/01/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024] Open
Abstract
Cardiac sarcoidosis (CS) is a form of inflammatory cardiomyopathy associated with significant clinical complications such as high-degree atrioventricular block, ventricular tachycardia, and heart failure as well as sudden cardiac death. It is therefore important to provide an expert consensus statement summarizing the role of different available diagnostic tools and emphasizing the importance of a multidisciplinary approach. By integrating clinical information and the results of diagnostic tests, an accurate, validated, and timely diagnosis can be made, while alternative diagnoses can be reasonably excluded. This clinical expert consensus statement reviews the evidence on the management of different CS manifestations and provides advice to practicing clinicians in the field on the role of immunosuppression and the treatment of cardiac complications based on limited published data and the experience of international CS experts. The monitoring and risk stratification of patients with CS is also covered, while controversies and future research needs are explored.
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Affiliation(s)
- Rakesh Sharma
- Department of Cardiology, Royal Brompton Hospital, part of Guy's and St Thomas's NHS Foundation Trust, London SW3 6NP, UK
- National Heart and Lung Institute, Imperial College London, UK
- King's College London, UK
| | - Vasileios Kouranos
- National Heart and Lung Institute, Imperial College London, UK
- Interstitial Lung Disease Unit, Royal Brompton Hospital, part of Guys and St. Thomas's Hospital, London, UK
| | - Leslie T Cooper
- Department of Cardiovascular Medicine, Mayo Clinic in Florida, 4500 San Pablo, Jacksonville, USA
| | - Marco Metra
- Cardiology Unit, ASST Spedali Civili, University of Brescia, Brescia, Italy
| | - Arsen Ristic
- Department of Cardiology, University of Belgrade, Pasterova 2, Floor 9, 11000 Belgrade, Serbia
| | - Bettina Heidecker
- Department for Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Campus Benjamin Franklin; Charité Universitätsmedizin Berlin, Berlin Institute of Health (BIH) at Charité, Berlin, Germany
| | - John Baksi
- National Heart and Lung Institute, Imperial College London, UK
- Cardiac MRI Unit, Royal Brompton Hospital, part of Guy's and St Thomas's NHS Foundation Trust, London, UK
| | - Eleanor Wicks
- Department of Cardiology, Oxford University Hospitals NHS Trust, Oxford, UK
- University College London, London, UK
| | - Jose L Merino
- La Paz University Hospital-IdiPaz, Universidad Autonoma, Madrid, Spain
| | | | - Massimo Imazio
- Department of Medicine, University of Udine, Udine, Italy
- Department of Cardiology, University Hospital Santa Maria della Misericordia, Udine, Italy
| | - Christian de Chillou
- Department of Cardiology, CHRU-Nancy, Université de Lorraine, Nancy, France
- Department of Cardiology, IADI, INSERM U1254, Université de Lorraine, Nancy, France
| | - Carsten Tschöpe
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Angiology and Intensive Medicine (Campus Virchow) and German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Center for Regenerative Therapies, Universitätsmedizin Berlin, Berlin, Germany
| | - Petr Kuchynka
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Steffen E Petersen
- NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University London, Charterhouse Square, London, EC1M 6BQ, UK
- Barts Heart Centre, St Bartholomew's Hospital, Barts Health NHS Trust, West Smithfield, EC1A 7BE, London, UK
| | | | - Thomas Lüscher
- Royal Brompton Hospital, part of Guys and St Thomas's NHS Foundation Trust, Professor of Cardiology at Imperial College and Kings College, London, UK
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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Yodogawa K, Fujimoto Y, Hagiwara K, Oka E, Hayashi H, Murata H, Yamamoto T, Iwasaki YK, Shimizu W. Possibility of steroid therapy without pacemaker implantation in patients with sarcoidosis presenting atrioventricular block. Letter to the editor (response to Koshida H, et al.). Heart Vessels 2023; 38:615. [PMID: 35802183 DOI: 10.1007/s00380-022-02138-4] [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: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Kenji Yodogawa
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan.
| | - Yuhi Fujimoto
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kanako Hagiwara
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Eiichiro Oka
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroshi Hayashi
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Hiroshige Murata
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Teppei Yamamoto
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Yu-Ki Iwasaki
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
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Danley K, Fidler MJ, Sadaf A, Okwuosa TM. Unusual vasovagal-type autonomic dysfunction secondary to immune checkpoint inhibitor therapy. BMJ Case Rep 2023; 16:e251034. [PMID: 36805877 PMCID: PMC10016300 DOI: 10.1136/bcr-2022-251034] [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: 02/22/2023] Open
Abstract
We present the case of a patient with oral squamous cell carcinoma treated with the programmed death ligand inhibitor, pembrolizumab, an immune checkpoint inhibitor. She subsequently developed vasovagal-type autonomic dysfunction thought to be secondary to the pembrolizumab. The patient's vasovagal symptoms resolved with the initiation of oral glucocorticoids.
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Affiliation(s)
- Kelsey Danley
- Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Mary Jo Fidler
- Oncology, Rush University Medical Center, Chicago, Illinois, USA
| | - Aliyah Sadaf
- Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Tochukwu M Okwuosa
- Division of Cardiology, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
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Hagiwara H, Watanabe M, Kadosaka T, Koizumi T, Kobayashi Y, Koya T, Nakao M, Tsuneta S, Kato Y, Komoriyama H, Kamada R, Nagai T, Kudo K, Anzai T. Fragmented QRS on 12-lead electrocardiogram predicts long-term prognosis in patients with cardiac sarcoidosis. Heart Vessels 2023; 38:803-816. [PMID: 36635468 DOI: 10.1007/s00380-022-02229-2] [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: 09/26/2022] [Accepted: 12/28/2022] [Indexed: 01/14/2023]
Abstract
Fragmented QRS (fQRS) on a 12-lead electrocardiogram is a known marker of fatal arrhythmias or cardiac adverse events in ischemic and non-ischemic cardiomyopathy patients. Nonetheless, the association between fQRS and clinical outcomes in patients with cardiac sarcoidosis (CS) remains unclear. Herein, we investigated whether fQRS is associated with long-term clinical outcomes in CS patients. A total of 78 patients who received immunosuppressive therapy (IST) for clinically diagnosed CS were retrospectively examined. Patients were classified into two groups according to the presence (n = 19) or absence (n = 59) of fQRS on electrocardiogram before IST. The primary outcome was the composite event of all-cause death, ventricular tachyarrhythmias (VTs), and hospitalization for heart failure. Results of late gadolinium enhancement on cardiac magnetic resonance imaging were also analyzed. During a median follow-up period of 3.7 years (interquartile range: 1.6-6.2 years), the primary outcome occurred more frequently in patients with fQRS than in those without (47% vs. 13%, log-rank p = 0.002). Multivariable Cox regression analyses showed that fQRS was an independent determinant of the primary outcome. The incidence of VTs, within 12 months of IST initiation, was comparable between the two groups; however, late-onset VTs, defined as those occurring ≥ 12 months after IST initiation, occurred more frequently in the fQRS group (21% vs. 2%, log-rank p = 0.002). The scar zone and scar border zone were greater in patients with fQRS than in those without it. In conclusion, our analysis suggests that fQRS is an independent predictor of adverse events, particularly late-onset VTs, in patients with CS.
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Affiliation(s)
- Hikaru Hagiwara
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Cardiovascular Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Masaya Watanabe
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan.
| | - Takahide Kadosaka
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Takuya Koizumi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuta Kobayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Taro Koya
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Motoki Nakao
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Satonori Tsuneta
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Yoshiya Kato
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
- Department of Cardiovascular Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Hirokazu Komoriyama
- Department of Cardiovascular Medicine, Kushiro City General Hospital, Kushiro, Japan
| | - Rui Kamada
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kohsuke Kudo
- Department of Diagnostic Imaging, Graduate School of Medicine, Hokkaido University, Kita-15 Nishi-7, Kita-Ku, Sapporo, 060-8638, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Evaluation and Catheter Ablation of Ventricular Arrhythmias in Cardiac Sarcoidosis. J Clin Med 2022; 11:jcm11226718. [PMID: 36431195 PMCID: PMC9694385 DOI: 10.3390/jcm11226718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 11/01/2022] [Accepted: 11/07/2022] [Indexed: 11/16/2022] Open
Abstract
Ventricular arrhythmias are a common clinical manifestation in patients with cardiac sarcoidosis (CS) and other arrhythmogenic inflammatory cardiomyopathies (AIC). The management of sustained ventricular arrhythmias in these patients presents unique challenges. Current therapies include immunosuppressive, antiarrhythmic agents, and catheter ablation. Significant progress has been made in deciphering the importance of patient selection for ablation, systematic preablation evaluation, and optimal ablation timing, as well as ablation approaches and techniques. In this overview, we discuss the evaluation and management of ventricular arrhythmias in patients with CS, focusing on catheter ablation, which has evolved into an effective approach in reducing the burden of ventricular arrhythmias in these patients in the context of multifaceted treatment along with medical therapies.
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Possibility of steroid therapy without pacemaker implantation in patients with sarcoidosis presenting atrioventricular block: letter to the editor (response to Yalta K et al.). Heart Vessels 2022; 38:755. [PMID: 35789420 DOI: 10.1007/s00380-022-02137-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 11/04/2022]
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Possibility of steroid therapy without pacemaker implantation in patients with sarcoidosis presenting atrioventricular block. Heart Vessels 2022; 37:1892-1898. [PMID: 35568741 DOI: 10.1007/s00380-022-02092-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 04/27/2022] [Indexed: 11/04/2022]
Abstract
Atrioventricular Block (AVB) is one of the common manifestations in cardiac sarcoidosis (CS). Although pacemaker implantation is generally recommended in patients with CS complicated by symptomatic AVB, some case reports have shown that they can be managed by steroid therapy without pacemaker implantation. The aim of this study was to evaluate the feasibility and effectiveness of steroid therapy without pacemaker implantation in patients with CS complicated by symptomatic AVB. We performed medical record review of consecutive ten CS patients who admitted Nippon Medical School Hospital for symptomatic second or third degree AVB between April 2015 and March 2021. Of the studied population, steroid therapy before pacemaker implantation was feasible in three patients with second degree AVB. Two of them showed subsequent recovery of atrioventricular conduction to 1:1, and they were managed by steroid therapy without pacemaker. The remaining one patient showed no improvement of atrioventricular conduction and required pacemaker implantation. Seven patients with third degree AVB required device implantation (pacemaker; n = 7, cardiac resynchronization therapy defibrillator; n = 1) before steroid therapy mainly because of hemodynamic instability. Steroid therapy without pacemaker implantation might be feasible, and possibly be effective in patients with CS presenting second degree AVB. However, the feasibility is limited in patients with third degree AVB.
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8
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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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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: 10] [Impact Index Per Article: 3.3] [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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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: 25] [Impact Index Per Article: 8.3] [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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Nabeta T, Hara M, Naruke T, Maemura K, Oki T, Yazaki M, Fujita T, Ikeda Y, Ishii S, Koitabashi T, Ako J. Clinical valuables related to resolution of complete or advanced atrioventricular block after steroid therapy in patients with cardiac sarcoidosis. J Arrhythm 2021; 37:1093-1100. [PMID: 34386137 PMCID: PMC8339084 DOI: 10.1002/joa3.12583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 05/16/2021] [Accepted: 06/01/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Prediction of atrioventricular block (AVB) resolution after steroid therapy in patients with cardiac sarcoidosis (CS) is difficult. METHODS We identified 24 patients with CS and complete or advanced AVB receiving steroid therapy. AVB resolution was assessed by reviewing surface electrocardiogram and the percentage of ventricular pacing required on subsequent device interrogation reports. RESULTS AVB resolution was noted in eight (33%) patients 1 year after receiving steroid therapy. Univariate Cox regression analysis demonstrated that left ventricular ejection fraction (LVEF) (hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.01-1.14, P = .016), interval from recognized AVB to start of steroid therapy (HR 0.98, 95% CI 0.95-0.99, P < .001), and lysozyme (HR 1.51, 95% CI 1.12-2.19, P = .013) were significantly associated with resolution of AVB. Combination of area under the curve (AUC) of each variable that was significantly related to resolution of AVB (AUC, 0.969; 95% CI 0.921-1.000, P < .001) was tended to be higher compared with each variable alone. CONCLUSIONS A shorter interval from recognition of AVB to start of steroid therapy, higher LVEF, and higher lysozyme levels were significantly associated with resolution of AVB after steroid therapy in patients with CS. The combination of each variable could be able to distinguish patients with resolution of AVB from those without.
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Affiliation(s)
- Takeru Nabeta
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Masahiko Hara
- Center for Community‐based Healthcare Research and EducationShimane UniversityMatsueJapan
| | - Takashi Naruke
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Kenji Maemura
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Takumi Oki
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Mayu Yazaki
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Teppei Fujita
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Yuki Ikeda
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Shunsuke Ishii
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Toshimi Koitabashi
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Junya Ako
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
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Belperio JA, Shaikh F, Abtin F, Fishbein MC, Saggar R, Tsui E, Lynch JP. Extrapulmonary sarcoidosis with a focus on cardiac, nervous system, and ocular involvement. EClinicalMedicine 2021; 37:100966. [PMID: 34258571 PMCID: PMC8254127 DOI: 10.1016/j.eclinm.2021.100966] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 02/07/2023] Open
Abstract
Sarcoidosis is a poorly understood granulomatous disease that involves the lungs and/or intrathoracic lymph nodes in more than 90% of cases. Although pulmonary sarcoidosis is the leading cause of mortality in this disease, this review focuses on three sites of extrapulmonary involvement (heart, nervous system, and eyes), since involvement of any of these sites can be catastrophic, leading to death, debilitation, or blindness. Patients with cardiac, ocular and neurosarcoidosis necessitate a multidisciplinary approach with careful and long-term follow-up. Prompt diagnosis with imaging and/or biopsy and treatment is required to avoid irreversible damage. Corticosteroids are the mainstay of therapy and are often associated with rapid and durable remissions. Immunosuppressive or biologic agents are reserved for patients failing or experiencing side effects from steroids. Managing sarcoidosis requires vigilance, judgement, and awareness of the vagaries of this fascinating disease.
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Affiliation(s)
- John A. Belperio
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Faisal Shaikh
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Fereidoun Abtin
- Department of Radiology, Thoracic and Interventional Section, David Geffen School of Medicine at UCLA, United States
| | - Michael C. Fishbein
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, United States
| | - Rajan Saggar
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
| | - Edmund Tsui
- Department of Ophthalmology, David Geffen School of Medicine at UCLA, United States
| | - Joseph P. Lynch
- The Division of Pulmonary and Critical Care Medicine, Holt and Jo Hickman Endowed Chair of Advanced Lung Disease and Lung Transplantation, Clinical Immunology, and Allergy, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Room 37-131 CHS, Los Angeles, CA 90095, United States
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13
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Lemay S, Massot M, Philippon F, Belzile D, Turgeon PY, Beaudoin J, Laliberté C, Fortin S, Dion G, Milot J, Trottier M, Gosselin J, Charbonneau É, Birnie DH, Sénéchal M. Ten Questions Cardiologists Should Be Able to Answer About Cardiac Sarcoidosis: Case-Based Approach and Contemporary Review. CJC Open 2021; 3:532-548. [PMID: 34027358 PMCID: PMC8129447 DOI: 10.1016/j.cjco.2020.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 11/24/2020] [Indexed: 12/17/2022] Open
Abstract
Sarcoidosis is an inflammatory multisystemic disease of unknown etiology characterized by the formation of noncaseating epithelioid cell granulomas. Cardiac sarcoidosis might be life-threatening and its diagnosis and treatment remain a challenge nowadays. The aim of this review is to provide an updated overview of cardiac sarcoidosis and, through 10 practical clinical questions and real-life challenging case scenarios, summarize the main clinical presentation, diagnostic criteria, imaging findings, and contemporary treatment.
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Affiliation(s)
- Sylvain Lemay
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Montse Massot
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - François Philippon
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - David Belzile
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Pierre Yves Turgeon
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Jonathan Beaudoin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Claudine Laliberté
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Sophie Fortin
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Geneviève Dion
- Department of Pneumology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Julie Milot
- Department of Pneumology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Mikaël Trottier
- Department of Nuclear Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Justin Gosselin
- Department of Internal Medicine, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - Éric Charbonneau
- Department of Cardiac Surgery, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
| | - David H. Birnie
- Department of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Mario Sénéchal
- Department of Cardiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Québec City, Québec, Canada
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14
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Rosenthal DG, Fang CD, Groh CA, Nah G, Vittinghoff E, Dewland TA, Vedantham V, Marcus GM. Heart Failure, Atrioventricular Block, and Ventricular Tachycardia in Sarcoidosis. J Am Heart Assoc 2021; 10:e017692. [PMID: 33599141 PMCID: PMC8174291 DOI: 10.1161/jaha.120.017692] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Sarcoidosis is a granulomatous disease usually affecting the lungs, although cardiac morbidity may be common. The risk of these outcomes and the characteristics that predict them remain largely unknown. This study investigates the epidemiology of heart failure, atrioventricular block, and ventricular tachycardia among patients with and without sarcoidosis. Methods and Results We identified California residents aged ≥21 years using the Office of Statewide Health Planning and Development ambulatory surgery, emergency, or inpatient databases from 2005 to 2015. The risk of sarcoidosis on incident heart failure, atrioventricular block, and ventricular tachycardia were each determined. Linkage to the Social Security Death Index was used to ascertain overall mortality. Among 22 527 964 California residents, 19 762 patients with sarcoidosis (0.09%) were identified. Sarcoidosis was the strongest predictor of heart failure (hazard ratio [HR], 11.2; 95% CI, 10.7-11.7), atrioventricular block (HR, 117.7; 95% CI, 103.3-134.0), and ventricular tachycardia (HR, 26.1; 95% CI, 24.2-28.1) identified among all risk factors. The presence of any cardiac involvement best predicted each outcome. Approximately 22% (95% CI, 18%-26%) of the relationship between sarcoidosis and increased mortality was explained by the presence of at least 1 of these cardiovascular outcomes. Conclusions The magnitude of risk associated with sarcoidosis as a predictor of heart failure, atrioventricular block, and ventricular tachycardia, exceeds all established risk factors. Surveillance for and anticipation of these outcomes among patients with sarcoidosis is indicated, and consideration of a sarcoidosis diagnosis may be prudent among patients with heart failure, atrioventricular block, or ventricular tachycardia.
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Affiliation(s)
- David G Rosenthal
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Christina D Fang
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Christopher A Groh
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Gregory Nah
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics University of California, San Francisco CA
| | - Thomas A Dewland
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Vasanth Vedantham
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
| | - Gregory M Marcus
- Division of Cardiology, Electrophysiology Section University of California, San Francisco CA
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15
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Ishida M, Niwano S, Fujiyoshi K, Ishida K, Ako J, Inomata T. A case with recovery from high degree atrioventricular-block with steroid therapy in cardiac sarcoidosis with AH block: a possible new sign of responder? J Cardiol Cases 2021; 23:90-93. [PMID: 33520031 DOI: 10.1016/j.jccase.2020.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/07/2020] [Accepted: 09/18/2020] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Although some reports have documented cases who exhibited recovery from atrioventricular block (AVB) by steroid therapy in cases with cardiac sarcoidosis (CS), they could not determine predictors for such good response to steroid therapy. In this case, a 54-year-old female was referred to our hospital due to intermittent 2:1 AVB. Echocardiography revealed normal ventricular function. 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) exhibited enhanced uptake in basal anterior-septal area of the left ventricle. The electrophysiologic study exhibited marked AH prolongation (324 ms) but no HV prolongation. Sarcoidosis was diagnosed basing on non-caseating granulomas detected in skin biopsy. Because the 2:1 AVB was temporal, oral prednisolone (PSL) was started without planning implantation of permanent pacemaker. In 10 days from start of PSL, PR interval was gradually normalized from 0.34 to 0.14 sec and temporal 2:1 AVB disappeared. 18F-FDG PET also exhibited disappearance of enhanced uptake. During the following 2 years, the patient continued to exhibit normal PR interval. This case exhibited AH prolongation in EPS, although the degree of AVB was serious. Additionally, 18F-FDG PET exhibited enhanced uptake in the area around AV-node. AH block and FDG enhancement around AV-node area might be novel predictors for good response to PSL in cases with CS. <Learning objective: Although early phase steroid therapy should be good for recovery of atrioventricular block in cardiac sarcoidosis (CS) cases, there is no useful predictor for the effect. Our case, a good responder to steroid therapy, exhibited fluorodeoxyglucose enhancement around AV node area and AH prolongation in electrophysiologic study. These findings might be good predictors for good response to steroid therapy in CS cases.>.
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Affiliation(s)
- Miwa Ishida
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Sagamihara, Kanagawa, Japan
| | - Shinichi Niwano
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Kazuhiro Fujiyoshi
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Sagamihara, Kanagawa, Japan
| | - Kohki Ishida
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Sagamihara, Kanagawa, Japan
| | - Junya Ako
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Sagamihara, Kanagawa, Japan
| | - Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, Sagamihara, Kanagawa, Japan
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16
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Gendelman HK, Sabha M, Gryaznov AA, Siaton BC. Recurrent Syncope Due to Concurrent Cardiac Sarcoidosis and Large-Vessel Vasculitis. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e927331. [PMID: 33510124 PMCID: PMC7851718 DOI: 10.12659/ajcr.927331] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Patient: Male, 68-year-old Final Diagnosis: Sarcoidosis • vasculitis Symptoms: Syncope Medication:— Clinical Procedure: — Specialty: Rheumatology
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Affiliation(s)
- Hannah K Gendelman
- Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marwa Sabha
- Division of Rheumatology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anton A Gryaznov
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bernadette C Siaton
- Division of Rheumatology, Department of Internal Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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17
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Ha FJ, Agarwal S, Tweed K, Palmer SC, Adams HS, Thillai M, Williams L. Imaging in Suspected Cardiac Sarcoidosis: A Diagnostic Challenge. Curr Cardiol Rev 2020; 16:90-97. [PMID: 31345153 PMCID: PMC7460708 DOI: 10.2174/1573403x15666190725121246] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/05/2019] [Accepted: 07/11/2019] [Indexed: 12/18/2022] Open
Abstract
Cardiac Sarcoidosis (CS) represents a unique diagnostic dilemma. Guidelines have been recently revised to reflect the established role of sophisticated imaging techniques. Trans-thoracic Echocardiography (TTE) is widely adopted for initial screening of CS. Contemporary TTE techniques could enhance detection of subclinical Left Ventricular (LV) dysfunction, particularly LV global longitudinal strain assessment which predicts event-free survival (meta-analysis of 5 studies, hazard ratio 1.28, 95% confidence interval 1.18-1.37, p < 0.0001). However, despite the wide availability of TTE, it has limited sensitivity and specificity for CS diagnosis. Cardiac Magnetic resonance Imaging (CMR) is a crucial diagnostic modality for suspected CS. Presence of late gadolinium enhancement signifies myocardial scar and enables risk stratification. Fluorodeoxyglucose Positron Emission Tomography (FDG-PET) coupled with myocardial perfusion imaging can identify active CS and guide immunosuppressant therapy. Gallium scintigraphy may be considered although FDG-PET is often preferred. While CMR and FDG-PET provide complementary information in CS evaluation, current guidelines do not recommend which imaging modalities are essential in suspected CS and if so, which modality should be performed first. The utility of hybrid imaging combining both advanced imaging modalities in a single scan is currently being explored, although not yet widely available. In view of recent, significant advances in cardiac imaging techniques, this review aims to discuss changes in guidelines for CS diagnosis, the role of various cardiac imaging modalities and the future direction in CS.
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Affiliation(s)
- Francis J Ha
- St Vincent's Hospital Melbourne, Victoria, Australia
| | - Sharad Agarwal
- Royal Papworth Hospital, NHS Foundation Trust, Cambridge, CB2 0AY, United Kingdom
| | - Katharine Tweed
- Royal Papworth Hospital, NHS Foundation Trust, Cambridge, CB2 0AY, United Kingdom
| | - Sonny C Palmer
- St Vincent's Hospital Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Victoria, Australia
| | - Heath S Adams
- St Vincent's Hospital Melbourne, Victoria, Australia
| | - Muhunthan Thillai
- Royal Papworth Hospital, NHS Foundation Trust, Cambridge, CB2 0AY, United Kingdom.,Department of Medicine University of Cambridge, Cambridge, CB2 0AY, United Kingdom
| | - Lynne Williams
- Royal Papworth Hospital, NHS Foundation Trust, Cambridge, CB2 0AY, United Kingdom
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18
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Rosenthal DG, Cheng RK, Petek BJ, Masri SC, Mikacenic C, Raghu G, Patton KK. Risk of Adverse Cardiovascular Events in Cardiac Sarcoidosis Independent of Left Ventricular Function. Am J Cardiol 2020; 127:142-148. [PMID: 32402485 DOI: 10.1016/j.amjcard.2020.04.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 02/02/2023]
Abstract
This study investigated the association between left ventricular ejection fraction (LVEF) and the risk of ventricular arrhythmias (VA), heart transplantation, and death in cardiac sarcoidosis (CS). We identified 110 CS patients meeting 2014 Heart Rhythm Society (HRS) diagnostic criteria with baseline LVEF <35% (n = 32) or ≥35% (n = 78). The primary end point was sustained VA or sudden cardiac death (SCD), and secondary end points included risk of heart transplantation, death, or a composite. Logistic regression determined risk factors for VA/SCD, and Cox proportional hazards regression analysis was performed for secondary end points. Receiver operating curve analysis determined the best discrimination point of LVEF for each end point; sensitivity analyses evaluated the effects of higher LVEF on each end point. Over a follow-up of 2.6 (range 1.0 to 5.8) years, 49 (44.5%) CS patients experienced VA/SCD, including 19 of 32 (59.4%) with LVEF <35%, and 30 of 78 (38.5%) with LVEF ≥35%. After adjustment, LVEF <35% was not significantly associated with an increased risk of VA/SCD compared with LVEF ≥35% (odds ratio 1.3, 95% confidence intervals 0.5 to 3.7). Although LVEF <35% was associated with an increased risk of heart transplantation and death (28.1% vs 12.8%, p = 0.05), this was not significant after adjustment (hazard ratio 1.7, 95% confidence intervals 0.5 to 9.0, p = 0.53). In conclusion, patients with CS experience high rates of VA, SCD, and heart transplantation, even when LVEF is mildly impaired or normal. Patients with LVEF <35% are at particularly elevated risk of VA/SCD. Our findings highlight the imperative to investigate arrhythmia risk in all patients with CS, even in the setting of an otherwise reassuring LVEF.
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19
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Ricci F, Mantini C, Grigoratos C, Bianco F, Bucciarelli V, Tana C, Mastrodicasa D, Caulo M, Donato Aquaro G, Raffaele Cotroneo A, Gallina S. The Multi-modality Cardiac Imaging Approach to Cardiac Sarcoidosis. Curr Med Imaging 2020; 15:10-20. [PMID: 31964322 DOI: 10.2174/1573405614666180522074320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 09/03/2017] [Accepted: 04/07/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Sarcoidosis is a multisystem granulomatous disease with a neglected but high prevalence of life-threatening cardiac involvement. DISCUSSION The clinical presentation of Cardiac Sarcoidosis (CS) depends upon the location and extent of the granulomatous inflammation, with left ventricular free wall the most common location followed by interventricular septum. The lack of a diagnostic gold standard and the unpredictable risk of sudden cardiac death pose serious challenges for the validation of accurate and effective screening test and the management of the disease. In the last few years advanced cardiac imaging modalities such as Cardiac Magnetic Resonance (CMR) and Positron Emission Tomography (PET) have significantly improved our knowledge and understanding of CS, and have also contributed in risk stratification, assessment of inflammatory activity and therapeutic monitoring of the disease. CONCLUSION In this review, we will discuss the state of the art in the diagnosis of CS focusing on the role and importance of multi-modality cardiac imaging.
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Affiliation(s)
- Fabrizio Ricci
- Department of Neuroscience, Imaging and Clinical Sciences, School of Advanced Studies, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, Section of Diagnostic Imaging and Therapy, Radiology Division, Italy
| | | | - Francesco Bianco
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, Italy
| | - Valentina Bucciarelli
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, Italy
| | - Claudio Tana
- Internal Medicine and Critical Subacute Care Unit, Medicine Geriatric-Rehabilitation Department, University-Hospital of Parma, Parma, Italy
| | - Domenico Mastrodicasa
- Department of Neuroscience, Imaging and Clinical Sciences, Section of Diagnostic Imaging and Therapy, Radiology Division, Italy
| | - Massimo Caulo
- Department of Neuroscience, Imaging and Clinical Sciences, Section of Diagnostic Imaging and Therapy, Radiology Division, Italy
| | | | - Antonio Raffaele Cotroneo
- Department of Neuroscience, Imaging and Clinical Sciences, Section of Diagnostic Imaging and Therapy, Radiology Division, Italy
| | - Sabina Gallina
- Department of Neuroscience, Imaging and Clinical Sciences, Institute of Cardiology, Italy
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20
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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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21
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Chiba T, Nakano M, Hasebe Y, Kimura Y, Fukasawa K, Miki K, Morosawa S, Takanami K, Ota H, Fukuda K, Shimokawa H. Prognosis and risk stratification in cardiac sarcoidosis patients with preserved left ventricular ejection fraction. J Cardiol 2020; 75:34-41. [DOI: 10.1016/j.jjcc.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 03/25/2019] [Accepted: 04/25/2019] [Indexed: 10/26/2022]
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22
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Terasaki F, Azuma A, Anzai T, Ishizaka N, Ishida Y, Isobe M, Inomata T, Ishibashi-Ueda H, Eishi Y, Kitakaze M, Kusano K, Sakata Y, Shijubo N, Tsuchida A, Tsutsui H, Nakajima T, Nakatani S, Horii T, Yazaki Y, Yamaguchi E, Yamaguchi T, Ide T, Okamura H, Kato Y, Goya M, Sakakibara M, Soejima K, Nagai T, Nakamura H, Noda T, Hasegawa T, Morita H, Ohe T, Kihara Y, Saito Y, Sugiyama Y, Morimoto SI, Yamashina A. JCS 2016 Guideline on Diagnosis and Treatment of Cardiac Sarcoidosis - Digest Version. Circ J 2019; 83:2329-2388. [PMID: 31597819 DOI: 10.1253/circj.cj-19-0508] [Citation(s) in RCA: 218] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Fumio Terasaki
- Medical Education Center / Department of Cardiology, Osaka Medical College
| | - Arata Azuma
- Department of Pulmonary Medicine, Nippon Medical School
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Nobukazu Ishizaka
- Department of Internal Medicine (III) / Department of Cardiology, Osaka Medical College
| | - Yoshio Ishida
- Department of Internal Medicine, Kaizuka City Hospital
| | - Mitsuaki Isobe
- Department of Cardiovascular Medicine, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
| | - Takayuki Inomata
- Department of Cardiology, Kitasato University Kitasato Institute Hospital
| | | | - Yoshinobu Eishi
- Department of Human Pathology, Graduate School of Medical and Dental Science, Tokyo Medical and Dental University
| | - Masafumi Kitakaze
- Department of Clinical Medicine and Development, National Cerebral and Cardiovascular Center
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine
| | | | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Kyushu University Graduate School of Medical Sciences
| | - Takatomo Nakajima
- Division of Cardiology, Saitama Cardiovascular and Respiratory Center
| | - Satoshi Nakatani
- Division of Functional Diagnostics, Department of Health Sciences, Osaka University Graduate School of Medicine
| | - Taiko Horii
- Department of Cardiovascular Surgery, Kagawa University School of Medicine
| | | | - Etsuro Yamaguchi
- Department of Respiratory Medicine and Allergology, Aichi Medical University School of Medicine
| | | | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Hideo Okamura
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiko Goya
- Department of Cardiology, Tokyo Medical and Dental University
| | - Mamoru Sakakibara
- Department of Cardiovascular Medicine, Hokkaido University Graduate School of Medicine
| | - Kyoko Soejima
- Department of Cardiology, Kyorin University Faculty of Medicine
| | - Toshiyuki Nagai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Takashi Noda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Takuya Hasegawa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Tohru Ohe
- Department of Cardiology, Sakakibara Heart Institute of Okayama
| | - Yasuki Kihara
- Department of Cardiovascular Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University
| | - Yoshihiko Saito
- Department of Cardiorenal Medicine and Metabolic Disease, Nara Medical University
| | - Yukihiko Sugiyama
- Division of Pulmonary Medicine, Department of Medicine, Jichi Medical University
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23
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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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Okada DR, Xie E, Assis F, Smith J, Derakhshan A, Gowani Z, Ambale-Venkatesh B, Gilotra NA, Zimmerman SL, Berger RD, Calkins H, Lima JAC, Tandri H, Chrispin J. Regional abnormalities on cardiac magnetic resonance imaging and arrhythmic events in patients with cardiac sarcoidosis. J Cardiovasc Electrophysiol 2019; 30:1967-1976. [PMID: 31328324 DOI: 10.1111/jce.14082] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/03/2019] [Accepted: 06/19/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with cardiac sarcoidosis (CS) may present with arrhythmic events (AE): atrioventricular block (AVB) and/ or ventricular arrhythmias (VA). We sought to: (a) use regional analysis of cardiac magnetic resonance imaging (CMR) to describe anatomic and functional phenotypes of patients with CS and AE; (b) Assess the association of regional CMR abnormalities with the combined endpoint of death, heart transplantation (HT) and AE; and (c) use machine learning (ML) to predict the combined endpoint based on CMR features. METHODS we included 76 patients with CS and CMR. We analyzed cine images to determine regional longitudinal (LS) and radial strain (RS); and late gadolinium enhancement imaging to determine regional scar burden (%scar). RESULTS Patients with AVB (n = 7), compared with those without, had higher %scar in the anterior (21.8 ± 27.4 vs 5.1 ± 8.9; P = 0.0005) and anteroseptal (19.3 ± 24.5 vs 3.5 ± 5.5; P < .0001) walls. Patients with VA (n = 12), compared with those without, had higher %scar in the basal inferoseptum (20.4 ± 30.8 vs 8.3 ± 13.4; P = .03). During mean follow-up of 4.4 ± 3.3 years, four patients died or underwent HT; eight had VA; and zero developed AVB. Multiple regional abnormalities were associated with the combined endpoint, including scar in the anteroseptal wall (HR 1.06 [1.02-1.09] per 1%scar increase, P = .002). The ML algorithm predicted the combined endpoint with a C-statistic of 0.91. CONCLUSION Regional CMR abnormalities are associated with AE in patients with CS.
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Affiliation(s)
- David R Okada
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Eric Xie
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Fabrizio Assis
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - John Smith
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Arsalan Derakhshan
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Zain Gowani
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | | | - Ronald D Berger
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Hugh Calkins
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland.,Department of Radiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Harikrishna Tandri
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Jonathan Chrispin
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, Maryland
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Bolourchi M, Silver ES, Liberman L. Advanced Heart Block in Children with Lyme Disease. Pediatr Cardiol 2019; 40:513-517. [PMID: 30377753 DOI: 10.1007/s00246-018-2003-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/28/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND The clinical course of children with advanced heart block secondary to Lyme disease has not been well characterized. OBJECTIVE To review the presentation, management, and time to resolution of heart block due to Lyme disease in previously healthy children. METHODS An IRB approved single-center retrospective study was conducted of all patients < 21 years old with confirmed Lyme disease and advanced second or third degree heart block between 2007 and 2017. RESULTS Twelve patients (100% male) with a mean age of 15.9 years (range 13.2-18.1) were identified. Six patients (50%) had mild to moderate atrioventricular valve regurgitation and all had normal biventricular function. Five patients had advanced second degree heart block and 7 had complete heart block with an escape rate of 20-57 bpm. Isoproterenol was used in 4 patients for 3-4 days and one patient required transvenous pacing for 2 days. Patients were treated with 21 days (n = 6, 50%) or 28 days (n = 6, 50%) of antibiotics. Three patients received steroids for 3-4 days. Advanced heart block resolved in all patients within 2-5 days, and all had a normal PR interval within 3 days to 16 months from hospital discharge. CONCLUSION Symptomatic children who present with new high-grade heart block from an endemic area should be tested for Lyme disease. Antibiotic therapy provides quick and complete resolution of advanced heart block within 5 days, while steroids did not appear to shorten the time course in this case series. Importantly, no patients required a permanent pacemaker.
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Affiliation(s)
- Meena Bolourchi
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University, College of Physicians and Surgeons, 3959 Broadway, 2-North, New York, NY, USA
| | - Eric S Silver
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University, College of Physicians and Surgeons, 3959 Broadway, 2-North, New York, NY, USA
| | - Leonardo Liberman
- Department of Pediatrics, Division of Pediatric Cardiology, Columbia University, College of Physicians and Surgeons, 3959 Broadway, 2-North, New York, NY, USA.
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Chen XY, Ren ZC, Huang XJ. Sarcoidosis of the medulla oblongata causing intractable hiccoughs and numbness of extremities: A case report. Medicine (Baltimore) 2018; 97:e13667. [PMID: 30558069 PMCID: PMC6320214 DOI: 10.1097/md.0000000000013667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Sarcoidosis is a multisystem disorder characterized by noncaseating granulomas. The nervous system is involved in 5 to 16% of the patients. However, neurosarcoidosis in the medulla oblongata presenting as hiccough is remarkably rare. PATIENT CONCERN A 55-year-old female was admitted to our hospital suffering from intractable hiccough and progressive numbness of extremities. DIAGNOSIS The MR imaging revealed a circumscribed mass lesion located on the medulla oblongata. The mass was hyperintense on T2-weighted images and enhanced homogeneously with gadolinium-diethylenetriamine penta-acetic acid. The cerebrospinal fluid analysis showed a moderately elevated protein content and a significant lymphocytosis 86.5%. Electrocardiogram (ECG) showed complete atrioventricular block. Bilateral supraclavicular, hilar, and mediastinal lymphadenopathy was diagnosed in a CT scan. Transbranchial needle aspiration biopsy revealed noncaseating granuloma consisting of epithelioid cells, lymphocytes, and rare multinucleated giant cells which was consistent with sarcoidosis. The diagnosis of multisystemic sarcoidosis was made. INTERVENTIONS AND OUTCOMES The patient underwent a permanent pacemaker insertion, and was successfully treated with corticosteroids. LESSONS It is important to consider neurosarcoidosis in the differential diagnosis of intramedullary lesion, since a right recognition may lead to appropriate treatment with steroids and avoid needlessly extensive surgery.
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Park H, Park JC, Cho JY, Yoon HJ, Kim KH, Ahn Y, Jeong MH, Cho JG. Recovery of High Degree Atrioventricular Block in a Patient with Cardiac Sarcoidosis by Corticosteroid Therapy. Chonnam Med J 2018; 54:74-75. [PMID: 29399570 PMCID: PMC5794483 DOI: 10.4068/cmj.2018.54.1.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 11/26/2017] [Accepted: 12/06/2017] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hyukjin Park
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Yoon
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Kye Hun Kim
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- Division of Cardiology, Chonnam National University Hospital, Gwangju, Korea
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Abstract
Inflammatory activation occurs in nearly all forms of myocardial injury. In contrast, inflammatory cardiomyopathies refer to a diverse group of disorders in which inflammation of the heart (or myocarditis) is the proximate cause of myocardial dysfunction, causing injury that can range from a fully recoverable syndrome to one that leads to chronic remodeling and dilated cardiomyopathy. The most common cause of inflammatory cardiomyopathies in developed countries is lymphocytic myocarditis most commonly caused by a viral pathogenesis. In Latin America, cardiomyopathy caused by Chagas disease is endemic. The true incidence of myocarditis is unknown to the limited utilization and the poor sensitivity of endomyocardial biopsies (especially for patchy diseases such as lymphocytic myocarditis and sarcoidosis) using the gold-standard Dallas criteria. Emerging immunohistochemistry criteria and molecular diagnostic techniques are being developed that will improve diagnostic yield, provide additional clues into the pathophysiology, and offer an application of precision medicine to these important syndromes. Immunosuppression is recommended for patients with cardiac sarcoidosis, giant cell myocarditis, and myocarditis associated with connective tissue disorders and may be beneficial in chronic viral myocarditis once virus is cleared. Further trials of immunosuppression, antiviral, and immunomodulating therapies are needed. Together, with new molecular-based diagnostics and therapies tailored to specific pathogeneses, the outcome of patients with these disorders may improve.
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Affiliation(s)
- Barry H Trachtenberg
- From the Houston Methodist DeBakey Heart and Vascular Center (B.H.T.), TX; University of Miami Leonard Miller School of Medicine, FL (J.M.H.); and Interdisciplinary Stem Cell Institute, Miami, FL (J.M.H.)
| | - Joshua M Hare
- From the Houston Methodist DeBakey Heart and Vascular Center (B.H.T.), TX; University of Miami Leonard Miller School of Medicine, FL (J.M.H.); and Interdisciplinary Stem Cell Institute, Miami, FL (J.M.H.).
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Chapelon-Abric C, Sene D, Saadoun D, Cluzel P, Vignaux O, Costedoat-Chalumeau N, Piette JC, Cacoub P. Cardiac sarcoidosis: Diagnosis, therapeutic management and prognostic factors. Arch Cardiovasc Dis 2017; 110:456-465. [PMID: 28566197 DOI: 10.1016/j.acvd.2016.12.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 10/25/2016] [Accepted: 12/17/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cardiac sarcoidosis (CS) is a severe localization, observed mostly in cardiology departments. Despite appropriate cardiological treatment, CS is a potentially life-threatening condition, and accounts for 13-85% of sarcoidosis-related deaths. AIMS This retrospective study aimed to give an overview of CS in a non-cardiac unit, to analyse the effect of first-line immunosuppressive treatment on outcome and survival and to evaluate factors associated with relapses. METHODS From 534 cases of sarcoidosis, we selected 59 patients with CS according to "2006 international criteria". We performed an in-depth analysis regarding symptoms, physical signs and cardiac investigation results. Patients were followed for a median period of 60 months. RESULTS The median age at cardiac signs was 42 years. Echocardiography abnormalities, isotopic defects and abnormal magnetic resonance imaging findings were observed in 81%, 84% and 92% of patients, respectively. First-line treatment included steroids alone in 24 patients and steroids plus immunosuppressive therapy in 35 patients. Forty-seven (80%) patients recovered; 12 stabilized or worsened. The recovery rate was 75% in the steroids alone group versus 83% in the steroids plus immunosuppressive therapy group. Five (9%) patients died during follow-up, with two deaths attributed to CS. The overall 1- and 5-year survival rates were 98% and 92%, respectively. CONCLUSION Our series of patients with CS who received steroids alone or combined with immunosuppressive therapy had a good prognosis, with an overall 5-year survival rate of 92%. The recovery rate was 85%, with no significant difference between patients treated with steroids alone or plus immunosuppressive therapy.
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Affiliation(s)
- Catherine Chapelon-Abric
- Département de Médecine Interne et d'Immunologie Clinique, CHU Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
| | - Damien Sene
- Département Médecine Interne, Hôpital Lariboisière, 75475 Paris, France
| | - David Saadoun
- Département de Médecine Interne et d'Immunologie Clinique, CHU Pitié-Salpétrière, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - Philippe Cluzel
- Service de Radiologie, CHU Pitié-Salpétrière, 75013 Paris, France
| | | | | | | | - Patrice Cacoub
- UMR 7211, Inflammation-Immunopathology-Biotherapy Department, Département de Médecine Interne et d'Immunologie Clinique, Sorbonne Universités, UPMC Université Paris, CHU Pitié-Salpétrière, 75005 Paris, France
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30
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Bravo PE, Raghu G, Rosenthal DG, Elman S, Petek BJ, Soine LA, Maki JH, Branch KR, Masri SC, Patton KK, Caldwell JH, Krieger EV. Risk assessment of patients with clinical manifestations of cardiac sarcoidosis with positron emission tomography and magnetic resonance imaging. Int J Cardiol 2017; 241:457-462. [PMID: 28318664 DOI: 10.1016/j.ijcard.2017.03.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Revised: 02/17/2017] [Accepted: 03/07/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND Prior studies have shown that late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and fluorodeoxyglucose (FDG) positron emission tomography (PET) confer incremental risk assessment in patients with cardiac sarcoidosis (CS). However, the incremental prognostic value of the combined use of LGE and FDG compared to either test alone has not been investigated, and this is the aim of the present study. METHODS Retrospective observational study of 56 symptomatic patients with high clinical suspicion for CS who underwent LGE-CMR and FDG-PET and were followed for the occurrence of death and/or malignant ventricular arrhythmias (VA). RESULTS The combination of PET and CMR yielded the following groups: 1) LGE-negative/normal-PET (n=20), 2) LGE-positive/abnormal-FDG (n=20), and 3) LGE-positive/normal FDG (n=16). After a median follow-up of 2.6years (IQR 1.2-4.1), 16 patients had events (7 deaths, 10 VA). All, but 1, events occurred in patients with LGE. LGE-positive/abnormal-FDG (7 events, HR 10.1 [95% CI 1.2-84]; P=0.03) and LGE-positive/normal-FDG (8 events, HR 13.3 [1.7-107]; P=0.015) patients had comparable risk of events compared to the reference LGE-negative/normal-PET group. In adjusted Cox-regression analysis, presence of LGE (HR 18.1 [1.8-178]; P=0.013) was the only independent predictor of events. CONCLUSION CS patients with LGE alone or in association with FDG were at similar risk of future events, which suggests that outcomes may be driven by the presence of LGE (myocardial fibrosis) and not FDG (inflammation).
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Affiliation(s)
- Paco E Bravo
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States; Noninvasive Cardiovascular Imaging Program, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.
| | - Ganesh Raghu
- Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - David G Rosenthal
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, United States
| | - Shana Elman
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Bradley J Petek
- University of Washington School of Medicine, Seattle, WA, United States
| | - Laurie A Soine
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States; Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Jeffrey H Maki
- Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Kelley R Branch
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Sofia C Masri
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Kristen K Patton
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States
| | - James H Caldwell
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States; Department of Radiology, University of Washington School of Medicine, Seattle, WA, United States
| | - Eric V Krieger
- Division of Cardiology, University of Washington School of Medicine, Seattle, WA, United States
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Padala SK, Peaslee S, Sidhu MS, Steckman DA, Judson MA. Impact of early initiation of corticosteroid therapy on cardiac function and rhythm in patients with cardiac sarcoidosis. Int J Cardiol 2017; 227:565-570. [DOI: 10.1016/j.ijcard.2016.10.101] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 10/30/2016] [Indexed: 12/21/2022]
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Komada T, Suzuki K, Ishiguchi H, Kawai H, Okumura T, Hirashiki A, Naganawa S. Magnetic resonance imaging of cardiac sarcoidosis: an evaluation of the cardiac segments and layers that exhibit late gadolinium enhancement. NAGOYA JOURNAL OF MEDICAL SCIENCE 2016; 78:437-446. [PMID: 28008199 PMCID: PMC5159469 DOI: 10.18999/nagjms.78.4.437] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/23/2016] [Indexed: 12/28/2022]
Abstract
Cardiac sarcoidosis (CS) can cause sudden death, which is the leading cause of mortality in patients with sarcoidosis in Japan. However, it is difficult to diagnose CS because of the lack of a sensitive diagnostic method for the condition. Late gadolinium-enhanced cardiac magnetic resonance (MR) imaging demonstrates improved sensitivity for diagnosing CS. Therefore, it is important to know the late gadolinium-enhancement (LGE) characteristics of CS on cardiac MR images in order to diagnose CS accurately. In this study, we investigated the most common sites of LGE on cardiac MR images in CS. Late gadolinium-enhanced MR images of 9 consecutive patients with CS (obtained between August 2009 and July 2015) were reviewed by two radiologists. The distribution of LGE was evaluated using the American Heart Association 17-segment model of the left ventricle. The LGE in each segment was also classified into 4 patterns according to the myocardial layer in which it occurred (the subepicardial, subendocardial, intramural, and transmural layer patterns). All 9 patients exhibited LGE in their left ventricle, and 70 of 153 (46%) myocardial segments were enhanced. All of the patients displayed LGE in the basal septal wall. The patients' LGE layer patterns were as follows: subepicardial: 40% (28/70), intramural: 30% (21/70), subendocardial: 16% (11/70), and transmural: 14% (10/70). The basal septum wall and subepicardial layer often exhibit LGE on cardiac MR images in CS patients. LGE can be observed in other segments and layers in some cases.
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Affiliation(s)
- Tomohiro Komada
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Kojiro Suzuki
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hiroaki Ishiguchi
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hisashi Kawai
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takahiro Okumura
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Akihiro Hirashiki
- Department of Advanced Medicine in Cardiopulmonary Disease, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Shinji Naganawa
- Department of Radiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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Perez IE, Garcia MJ, Taub CC. Multimodality Imaging in Cardiac Sarcoidosis: Is There a Winner? Curr Cardiol Rev 2016; 12:3-11. [PMID: 25784137 PMCID: PMC4807716 DOI: 10.2174/1573403x11666150318110406] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 03/10/2015] [Indexed: 11/22/2022] Open
Abstract
Sarcoidosis is a multisystem granulomatous disease of unknown cause that can affect the heart. Cardiac sarcoidosis may be present in as many as 25% of patients with systemic sarcoidosis, and it is frequently underdiagnosed. The early and accurate diagnosis of myocardial involvement is challenging. Advanced imaging techniques play important roles in the diagnosis and management of patients with cardiac sarcoidosis.
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Affiliation(s)
- Irving E Perez
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY. 1825 Eastchester Road Bronx, NY, 10461, USA.
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Rajapreyar I, Langlois E. Cardiac Sarcoidosis: Sorting Fact from Fiction in This Rare Cardiomyopathy. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2015. [DOI: 10.15212/cvia.2015.0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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35
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Rosenthal DG, Bravo PE, Patton KK, Goldberger ZD. Management of Arrhythmias in Cardiac Sarcoidosis. Clin Cardiol 2015; 38:635-40. [PMID: 26175285 DOI: 10.1002/clc.22430] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/04/2015] [Accepted: 05/08/2015] [Indexed: 12/15/2022] Open
Abstract
The prevalence of cardiac involvement in sarcoidosis is under-recognized and is associated with multiple complications, including conduction block, arrhythmias, and sudden death. The comparative roles of common therapies have been inadequately studied. The purpose of this review is to examine the literature regarding treatments utilized to manage arrhythmias associated with cardiac sarcoidosis.
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Affiliation(s)
- David G Rosenthal
- Department of Internal Medicine, University of Washington Medical Center, Seattle, Washington
| | - Paco E Bravo
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Kristen K Patton
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
| | - Zachary D Goldberger
- Division of Cardiology, University of Washington Medical Center, Seattle, Washington
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Dubrey SW, Sharma R, Underwood R, Mittal T. Cardiac sarcoidosis: diagnosis and management. Postgrad Med J 2015; 91:384-94. [PMID: 26130811 DOI: 10.1136/postgradmedj-2014-133219] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 06/12/2015] [Indexed: 12/19/2022]
Abstract
Cardiac sarcoidosis is one of the most serious and unpredictable aspects of this disease state. Heart involvement frequently presents with arrhythmias or conduction disease, although myocardial infiltration resulting in congestive heart failure may also occur. The prognosis in cardiac sarcoidosis is highly variable, which relates to the heterogeneous nature of heart involvement and marked differences between racial groups. Electrocardiography and echocardiography often provide the first clue to the diagnosis, but advanced imaging studies using positron emission tomography and MRI, in combination with nuclear isotope perfusion scanning are now essential to the diagnosis and management of this condition. The identification of clinically occult cardiac sarcoidosis and the management of isolated and/or asymptomatic heart involvement remain both challenging and contentious. Corticosteroids remain the first treatment choice with the later substitution of immunosuppressive and steroid-sparing therapies. Heart transplantation is an unusual outcome, but when performed, the results are comparable or better than heart transplantation for other disease states. We review the epidemiology, developments in diagnostic techniques and the management of cardiac sarcoidosis.
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Affiliation(s)
- S W Dubrey
- Department of Cardiology, Hillingdon Hospital, Uxbridge, UK
| | - R Sharma
- Department of Cardiology, The Royal Brompton Hospital, London, UK
| | - R Underwood
- Department of Radiology, Harefield Hospital, Harefield, UK
| | - T Mittal
- Department of Radiology, Harefield Hospital, Harefield, UK
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Nagao S, Watanabe H, Sobue Y, Kodama M, Tanaka J, Tanabe N, Suzuki E, Narita I, Watanabe E, Aizawa Y, Minamino T. Electrocardiographic abnormalities and risk of developing cardiac events in extracardiac sarcoidosis. Int J Cardiol 2015; 189:1-5. [DOI: 10.1016/j.ijcard.2015.03.175] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 02/13/2015] [Accepted: 03/15/2015] [Indexed: 10/23/2022]
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Jeudy J, Burke AP, White CS, Kramer GBG, Frazier AA. Cardiac Sarcoidosis: The Challenge of Radiologic-Pathologic Correlation:From the Radiologic Pathology Archives. Radiographics 2015; 35:657-79. [DOI: 10.1148/rg.2015140247] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Cardiac sarcoidosis is a potentially life-threatening condition characterized by formation of granulomas in the heart, resulting in conduction disturbances, atrial and ventricular arrhythmias, and ventricular dysfunction. The presentation of cardiac sarcoidosis ranges from asymptomatic with an abnormal imaging scan, to palpitations, syncope, symptoms of congestive heart failure, and sudden cardiac death. Screening for cardiac sarcoidosis has not been standardized, but the presence of cardiac symptoms on medical history and physical examination, and an abnormal electrocardiogram (ECG), Holter monitoring, or echocardiogram has been shown to be highly sensitive for detecting cardiac sarcoidosis. A signal-averaged ECG might also have a role in screening for cardiac sarcoidosis in asymptomatic patients. Although endomyocardial biopsies are highly specific for the diagnosis of cardiac sarcoidosis, procedural yield is very low and appropriate findings on cardiac MRI or PET are, therefore, often used as diagnostic surrogates. Treatment for cardiac sarcoidosis usually involves immunosuppressive therapy, particularly corticosteroids. Additional therapy might be required, depending on the clinical presentation, including implantation of an internal defibrillator, antiarrhythmic agents, and catheter ablation.
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Houston BA, Mukherjee M. Cardiac sarcoidosis: clinical manifestations, imaging characteristics, and therapeutic approach. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2014; 8:31-7. [PMID: 25452702 PMCID: PMC4240214 DOI: 10.4137/cmc.s15713] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/12/2014] [Accepted: 10/21/2014] [Indexed: 12/26/2022]
Abstract
Sarcoidosis is a multi-system disease pathologically characterized by the accumulation of T-lymphocytes and mononuclear phagocytes into the sine qua non pathologic structure of the noncaseating granuloma. Cardiac involvement remains a key source of morbidity and mortality in sarcoidosis. Definitive diagnosis of cardiac sarcoidosis, particularly early enough in the disease course to provide maximal therapeutic impact, has proven a particularly difficult challenge. However, major advancements in imaging techniques have been made in the last decade. Advancements in imaging modalities including echocardiography, nuclear spectroscopy, positron emission tomography, and magnetic resonance imaging all have improved our ability to diagnose cardiac sarcoidosis, and in many cases to provide a more accurate prognosis and thus targeted therapy. Likewise, therapy for cardiac sarcoidosis is beginning to advance past a “steroids-only” approach, as novel immunosuppressant agents provide effective steroid-sparing options. The following focused review will provide a brief discussion of the epidemiology and clinical presentation of cardiac sarcoidosis followed by a discussion of up-to-date imaging modalities employed in its assessment and therapeutic approaches.
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Affiliation(s)
- Brian A Houston
- Division of Cardiology, Department of Medicine, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Monica Mukherjee
- Division of Cardiology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
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Effect of corticosteroid on arrhythmic events in patients with cardiac sarcoidosis. J Cardiol 2013; 62:326-7. [PMID: 24169440 DOI: 10.1016/j.jjcc.2013.09.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 09/13/2013] [Indexed: 11/23/2022]
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