Pathophysiology and clinical management of cardiac sarcoidosis

Management of cardiac sarcoidosis

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.

A Comprehensive Review on the Electrocardiographic Manifestations of Cardiac Sarcoidosis: Patterns and Prognosis

PURPOSE OF REVIEW

Cardiac sarcoidosis (CS) refers to cardiac involvement in sarcoidosis and is usually associated with worse outcomes. This comprehensive review aims to elucidate the electrocardiographic (ECG) signs and features associated with CS, as well as examine modern techniques and their importance in CS evaluation.

RECENT FINDINGS

The exact pathogenesis of CS is still unclear, but it stems from an abnormal immunological response triggered by environmental factors in individuals with genetic predisposition. CS presents with non-cardiac symptoms; however, conduction system abnormalities are common in patients with CS. The most common electrocardiographic (ECG) signs include atrioventricular blocks and ventricular tachyarrhythmia. Distinct patterns, such as fragmented QRS complexes, T-wave alternans, and bundle branch blocks, are critical indicators of myocardial involvement. The application of advanced ECG techniques such as signal-averaged ECG, Holter monitoring, wavelet-transformed ECG, microvolt T-wave alternans, and artificial intelligence-supported analysis holds promising outcomes for opportune detection and monitoring of CS. Timely utilisation of inexpensive and readily available ECG possesses the potential to allow early detection and intervention for CS. The integration of artificial intelligence models into ECG analysis is a promising approach for improving the ECG diagnostic accuracy and further risk stratification of patients with CS.

Arrhythmias in Cardiac Sarcoidosis: Management and Prognostic Implications

Cardiac sarcoidosis (CS) is characterized by various arrhythmic manifestations ranging from catastrophic sudden cardiac death secondary to ventricular arrhythmia, severe conduction disease, sinus node dysfunction, and atrial fibrillation. The management of CS is complex and includes not only addressing the arrhythmia but also controlling the myocardial inflammation resultant from the autoimmune reaction. Arrhythmic manifestations of CS carry significant prognostic implications and invariably affect long-term survival in these patients. In this review, we focus on management of arrhythmic manifestation of cardiac sarcoidosis as well as risk stratification for sudden cardiac death in these patients.

Diagnosis and Management of Cardiac Sarcoidosis: A Scientific Statement From the American Heart Association

Cardiac sarcoidosis is an infiltrative cardiomyopathy that results from granulomatous inflammation of the myocardium and may present with high-grade conduction disease, ventricular arrhythmias, and right or left ventricular dysfunction. Over the past several decades, the prevalence of cardiac sarcoidosis has increased. Definitive histological confirmation is often not possible, so clinicians frequently face uncertainty about the accuracy of diagnosis. Hence, the likelihood of cardiac sarcoidosis should be thought of as a continuum (definite, highly probable, probable, possible, low probability, unlikely) rather than in a binary fashion. Treatment should be initiated in individuals with clinical manifestations and active inflammation in a tiered approach, with corticosteroids as first-line treatment. The lack of randomized clinical trials in cardiac sarcoidosis has led to treatment decisions based on cohort studies and consensus opinions, with substantial variation observed across centers. This scientific statement is intended to guide clinical practice and to facilitate management conformity by providing a framework for the diagnosis and management of cardiac sarcoidosis.

Trends and Disparities in Cardiovascular Death in Sarcoidosis: A Population-Based Retrospective Study in the United States From 1999 to 2020

BACKGROUND

Despite significant cardiac involvement in sarcoidosis, real-world data on death due to cardiovascular disease among patients with sarcoidosis is not well established.

METHODS AND RESULTS

We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for data on patients with sarcoidosis aged ≥25 years from 1999 to 2020. Diseases of the circulatory system except ischemic heart disease were listed as the underlying cause of death, and sarcoidosis was stated as a contributing cause of death. We calculated age-adjusted mortality rate (AAMR) per 1 million individuals and determined the trends over time by estimating the annual percentage change using the Joinpoint Regression Program. Subgroup analyses were performed on the basis of demographic and geographic factors. In the 22-year study period, 3301 cardiovascular deaths with comorbid sarcoidosis were identified. The AAMR from cardiovascular deaths with comorbid sarcoidosis increased from 0.53 (95% CI, 0.43-0.65) per 1 million individuals in 1999 to 0.87 (95% CI, 0.75-0.98) per 1 million individuals in 2020. Overall, women recorded a higher AAMR compared with men (0.77 [95% CI, 0.74-0.81] versus 0.58 [95% CI, 0.55-0.62]). People with Black ancestry had higher AAMR than people with White ancestry (3.23 [95% CI, 3.07-3.39] versus 0.39 [95% CI, 0.37-0.41]). A higher percentage of death was seen in the age groups of 55 to 64 years in men (23.11%) and women (21.81%), respectively. In terms of US census regions, the South region has the highest AAMR from cardiovascular deaths with comorbid sarcoidosis compared with other regions (0.78 [95% CI, 0.74-0.82]).

CONCLUSIONS

The increase of AAMR from cardiovascular deaths with comorbid sarcoidosis and higher cardiovascular mortality rates among adults aged 55 to 64 years highlight the importance of early screening for cardiovascular diseases among patients with sarcoidosis.

Racial disparities among patients with cardiac sarcoidosis and arrhythmias in the United States: A propensity matched-analysis from the national inpatient sample database 2016-2020

BACKGROUND

Cardiac sarcoidosis (CS) is frequently associated with conduction abnormalities and arrhythmias. In this study, we aim to evaluate racial disparities in the frequency of arrhythmias, and associated co-morbidities, among patients with CS.

METHODS

White and African American (AA) patients diagnosed with CS were identified and compared from the 2016-2020 National Inpatient Sample (NIS) database whilst adjusting for confounders via logistic regression models.

RESULTS

A total of 7,935 patients with CS were included in the study. The propensity-matched sample comprised of 5,570 patients, of whom 2,785 were White and 2,785 were AA. AA patients had a longer mean length of hospital stay (LOS) (7.84 vs. 6.94, p<0.01), a higher mean Charlson Comorbidity Index (CCI) score (3.10 vs. 2.84, p<0.01), and significantly higher incidences of cardiogenic shock [(9.2% vs 6.3%, p<0.01), aOR 1.45 (95% CI 1.17-1.78), p<0.01] and acute kidney injury (AKI) [(34.3% vs. 26.9%, p<0.01), aOR 1.41 (95% CI 1.24-1.61), p<0.01]. From an arrhythmia perspective, AA CS patients were shown to have a lower frequency of: (1) ventricular tachycardia (32.5% vs. 37.9%, p<0.01), (2) ventricular fibrillation (5.4% vs.7.2%, p<0.01), (3) first-degree AV block (1.8% vs. 4.1%, p<0.01), (4) complete AV block (6.3% vs. 14.2%, p<0.01), and (5) atrial fibrillation (31.8% vs. 34.8%, p=0.016) when compared to Whites with CS. Mortality remained higher for AAs (3.8% vs. 2.7%, p=0.024).

CONCLUSION

Our study demonstrates a higher incidence of cardiac arrhythmias among White patients but a higher incidence of cardiogenic shock, AKI, mean LOS, and mortality among AA patients with cardiac sarcoidosis.

Pathogenic pathways and therapeutic targets of inflammation in heart diseases: A focus on Interleukin-1

BACKGROUND

An exuberant and dysregulated inflammatory response contributes to the development and progression of cardiovascular diseases (CVDs).

METHODS

This narrative review includes original articles and reviews published over the past 20 years and found through PubMed. The following search terms (or combination of terms) were considered: "acute pericarditis," "recurrent pericarditis," "myocarditis," "cardiac sarcoidosis," "atherosclerosis," "acute myocardial infarction," "inflammation," "NLRP3 inflammasome," "Interleukin-1" and "treatment."

RESULTS

Recent evidence supports the role of inflammation across a wide spectrum of CVDs including myocarditis, pericarditis, inflammatory cardiomyopathies (i.e. cardiac sarcoidosis) as well as atherosclerotic CVD and heart failure. Interleukins (ILs) are the signalling mediators of the inflammatory response. The NACHT, leucine-rich repeat and pyrin-domain containing protein 3 (NLRP3) inflammasome play a key role in producing IL-1β, the prototypical pro-inflammatory cytokine involved in CVDs. Other pro-inflammatory cytokines (e.g. tumour necrosis factor) have been implicated in cardiac sarcoidosis. As a proof of this, IL-1 blockade has been proven efficacious in pericarditis and chronic coronary syndrome.

CONCLUSION

Tailored strategies aiming at quenching the inflammatory response have emerged as promising to treat CVDs. In this review article, we summarize recent evidence regarding the role of inflammation across a broad spectrum of CVDs. We also review novel evidence regarding targeted therapeutic strategies.

Case Report: Four cases of cardiac sarcoidosis in patients with inherited cardiomyopathy-a phenotypic overlap, co-existence of two rare cardiomyopathies or a second-hit disease

Cardiac sarcoidosis (CS), a rare condition characterized by non-caseating granulomas, can manifest with symptoms such as atrioventricular block and ventricular tachycardia (VT), as well as mimic inherited cardiomyopathies. A 48-year-old male presented with recurrent VT. The initial 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) scan showed uptake of the mediastinal lymph node. Cardiovascular magnetic resonance (CMR) demonstrated intramyocardial fibrosis. The follow-up 18FDG-PET scan revealed the presence of tracer uptake in the left ventricular (LV) septum, suggesting the likelihood of CS. Genetic testing identified a pathogenic LMNA variant. A 47-year-old female presented with complaints of palpitations and syncope. An Ajmaline provocation test confirmed Brugada syndrome (BrS). CMR revealed signs of cardiac inflammation. An endomyocardial biopsy (EMB) confirmed the diagnosis of cardiac sarcoidosis. Polymorphic VT was induced during an electrophysiological study, and an implantable cardioverter-defibrillator (ICD) was implanted. A 58-year-old woman presented with sustained VT with a prior diagnosis of hypertrophic cardiomyopathy (HCM). A genetic work-up identified the presence of a heterozygous MYBC3 variant of unknown significance (VUS). CMR revealed late gadolinium enhancement (LGE), while the 18FDG-PET scan demonstrated LV tracer uptake. The immunosuppressive therapy was adjusted, and no further VTs were observed. A 28-year-old male athlete with right ventricular dilatation and syncope experienced a cardiac arrest during training. Genetic testing identified a pathogenic mutation in PKP2. The autopsy has confirmed the presence of ACM and a distinctive extracardiac sarcoidosis. Cardiac sarcoidosis and inherited cardiomyopathies may interact in several different ways, altering the clinical presentation. Overlapping pathologies are frequently overlooked. Delayed or incomplete diagnosis risks inadequate treatment. Thus, genetic testing and endomyocardial biopsies should be recommended to obtain a clear diagnosis.

Machine-Learning-Based Diagnostics of Cardiac Sarcoidosis Using Multi-Chamber Wall Motion Analyses

BACKGROUND

Hindered by its unspecific clinical and phenotypical presentation, cardiac sarcoidosis (CS) remains a challenging diagnosis.

OBJECTIVE

Utilizing cardiac magnetic resonance imaging (CMR), we acquired multi-chamber volumetrics and strain feature tracking for a support vector machine learning (SVM)-based diagnostic approach to CS.

METHOD

Forty-five CMR-negative (CMR(-), 56.5(53.0;63.0)years), eighteen CMR-positive (CMR(+), 64.0(57.8;67.0)years) sarcoidosis patients and forty-four controls (CTRL, 56.5(53.0;63.0)years)) underwent CMR examination. Cardiac parameters were processed using the classifiers of logistic regression, KNN(K-nearest-neighbor), DT (decision tree), RF (random forest), SVM, GBoost, XGBoost, Voting and feature selection.

RESULTS

In a three-cluster analysis of CTRL versus vs. CMR(+) vs. CMR(-), RF and Voting classifier yielded the highest prediction rates (81.82%). The two-cluster analysis of CTRL vs. all sarcoidosis (All Sarc.) yielded high prediction rates with the classifiers logistic regression, RF and SVM (96.97%), and low prediction rates for the analysis of CMR(+) vs. CMR(-), which were augmented using feature selection with logistic regression (89.47%).

CONCLUSION

Multi-chamber cardiac function and strain-based supervised machine learning provides a non-contrast approach to accurately differentiate between healthy individuals and sarcoidosis patients. Feature selection overcomes the algorithmically challenging discrimination between CMR(+) and CMR(-) patients, yielding high accuracy predictions. The study findings imply higher prevalence of cardiac involvement than previously anticipated, which may impact clinical disease management.

Myocarditis: Etiology, Pathogenesis, and Their Implications in Clinical Practice

Myocarditis is an inflammatory disease of the myocardium caused by infectious or non-infectious agents. It can lead to serious short-term and long-term sequalae, such as sudden cardiac death or dilated cardiomyopathy. Due to its heterogenous clinical presentation and disease course, challenging diagnosis and limited evidence for prognostic stratification, myocarditis poses a great challenge to clinicians. As it stands, the pathogenesis and etiology of myocarditis is only partially understood. Moreover, the impact of certain clinical features on risk assessment, patient outcomes and treatment options is not entirely clear. Such data, however, are essential in order to personalize patient care and implement novel therapeutic strategies. In this review, we discuss the possible etiologies of myocarditis, outline the key processes governing its pathogenesis and summarize best available evidence regarding patient outcomes and state-of-the-art therapeutic approaches.

Cardiac sarcoidosis

The diagnostic yield of endomyocardial biopsy in cardiac sarcoidosis (CS) is quite low because of the patchy involvement, and for the diagnosis of CS, existing guidelines required histological confirmation. Therefore, especially for isolated CS, diagnosis consistent with the guidelines cannot be made in a large number of patients. With recent developments in imaging modalities such as cardiac magnetic resonance and 18-fluorodeoxyglucose positron emission tomography, diagnosing CS has become easier and diagnostic criteria for CS not compulsorily requiring histological confirmation have been suggested. Despite significant advances in diagnostic tools, large-scale studies that can guide treatment plans are still lacking, and treatment has relied on the experience accumulated over the past years and the consensus of experts. However, opinions vary, depending on the situation, which is quite puzzling for the physician treating CS. Moreover, with the advent of new immunosuppressant agents, these new drugs have been applied under the assumption that the effect of immunosuppression is not much different from that of other well-known autoimmune diseases that require immunosuppression. However, we should wait to see the beneficial effects of these new immunosuppressants before we attempt to apply these agents in our clinical practice. This review summarises the widely used diagnostic criteria, current diagnostic modalities and recommended treatments for sarcoidosis. We have added our opinions on selecting or modifying diagnostic and treatment plans from the diverse current recommendations.

The management of sarcoidosis in the 2020's by the primary care physician

Sarcoidosis is an idiopathic granulomatous disease that occurs worldwide and may affect any organ. Because the presenting symptoms of sarcoidosis are not specific for the disease, the primary care physician is usually the first provider to assess these patients. In addition, patients who have previously been diagnosed with sarcoidosis are usually followed longitudinally by primary care physicians. Therefore, these physicians are often the first to address sarcoidosis patient symptoms related to exacerbations of the disease, as well as first observe complications of sarcoidosis medications. This article outlines the approach to the evaluation, treatment and monitoring of sarcoidosis patients by the primary care physician.

Health-related quality of life in cardiac sarcoidosis: a systematic review

People living with cardiac sarcoidosis (CS) are likely to have worse clinical outcomes and greater impairment on health-related quality of life (HRQoL) than other sarcoidosis manifestations. CS can result in a constellation of intrusive symptoms (such as palpitations, dizziness, syncope/pre-syncope, chest pain, dyspnoea, orthopnoea, or peripheral oedema) and/or life-threatening episodes, requiring consideration of invasive cardiac procedures for diagnosis and for the management of acute events. Additionally, the presence of multisystemic involvement and persistent non-specific sarcoidosis symptoms negatively affect HRQoL. A systematic review was undertaken to explore the impact of CS on HRQoL in adults with CS. Multiple bibliographic databases were searched for studies with HRQoL as primary or secondary outcomes in CS (PROSPERO registration: CRD42019119752). Data extraction and quality assessments were undertaken independently by two authors. From the initial 1609 identified records, only 11 studies included CS patients but none specifically reported HRQoL scores for CS patients. The average representation of CS patients was 14.5% within these cohorts (range 2-22%). The majority (73%) was conducted in single-centre tertiary care settings, and only one study (9%) included longitudinal HRQoL data. CS patients were among those sarcoidosis patients with impaired HRQoL and worse outcomes, requiring higher doses of sarcoidosis-specific therapy which contribute to further deterioration of HRQoL. Sarcoidosis studies do not incorporate stratified HRQoL scores for CS patients. While there is a need for longitudinal and multicentre studies assessing HRQoL outcomes in CS cohorts, the development of CS-specific tools is also needed.

Radionuclide Assessment of Sarcoidosis

This review provides an overview of the techniques used in nuclear cardiology for the assessment of suspected or known cardiac sarcoidosis, how radionuclide imaging assists with regard to diagnosis, risk stratification, and monitoring response to therapy, and work that is on the horizon with novel tracers.

Myocardial Involvement in Systemic Autoimmune Rheumatic Diseases

Systemic autoimmune rheumatic diseases (SARDs) are defined by the potential to affect multiple organ systems, and cardiac involvement is a prevalent but often overlooked sequela. Myocardial involvement in SARDs is medicated by macrovascular disease, microvascular dysfunction, and myocarditis. Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, eosinophilic granulomatosis with polyangiitis, and sarcoidosis are associated with the greatest risk of myocardial damage and heart failure, though myocardial involvement is also seen in other SARDs or their treatments. Management of myocardial involvement should be disease-specific. Further research is required to elucidate targetable mechanisms of myocardial involvement in SARDs.

Clinical Outcomes of Radiologic Relapse in Patients With Cardiac Sarcoidosis Under Immunosuppressive Therapies

Although nuclear imaging can detect cardiac involvement of cardiac sarcoidosis (CS), including subclinical states, little is known about the prevalence and outcomes of radiologic relapse under prednisolone (PSL) therapy. This study aimed to investigate the clinical characteristics and outcomes in patients with radiologic relapse. A total of 80 consecutive patients with CS whose disease activity on nuclear imaging decreased at least once after initiation of immunosuppressive therapy were identified through a retrospective chart review. Radiologic relapse of CS was diagnosed using ¹⁸F-fluoro-2-deoxyglucose positron emission tomography or gallium-67 scintigraphy. Composite adverse events were defined as at least 1 of the following: all-cause death, hospitalization for heart failure, or lethal arrhythmia. During the follow-up period (median 2.9 years), radiologic relapse was observed in 31 patients (38.8% of overall patients) at 30 months (median) after immunosuppressive therapy initiation. After radiologic relapse was detected, all patients were treated with intensified immunosuppressive therapies (increasing PSL, n = 26 [83.9%], adding other immunosuppressive therapies to PSL, n = 5 [16.1%]). There were no differences in occurrences of composite adverse events in patients with and patients without radiologic relapse. Radiologic relapse under immunosuppressive therapy was observed in many patients with CS, but it was not associated with clinical outcomes under intensified immunosuppressive therapy.

Clinical Utilization of Multimodality Imaging for Myocarditis and Cardiac Sarcoidosis

Myocarditis is defined as inflammation of the myocardium according to clinical, histological, biochemical, immunohistochemical, or imaging findings. Inflammation can be categorized histologically by cell type or pattern, and many causes have been implicated, including infectious, most commonly viral, systemic autoimmune diseases, vaccine-associated processes, environmental factors, toxins, and hypersensitivity to drugs. Sarcoid myocarditis is increasingly recognized as an important cause of cardiomyopathy and has important diagnostic, prognostic, and therapeutic implications in patients with systemic sarcoidosis. The clinical presentation of myocarditis may include an asymptomatic, subacute, acute, fulminant, or chronic course and may have focal or diffuse involvement of the myocardium depending on the cause and time point of the disease. For most causes of myocarditis except sarcoidosis, myocardial biopsy is the gold standard but is limited due to risk, cost, availability, and variable sensitivity. Diagnostic criteria have been established for both myocarditis and cardiac sarcoidosis and include clinical and imaging findings particularly the use of cardiac magnetic resonance and positron emission tomography. Beyond diagnosis, imaging findings may also provide prognostic value. This case-based review focuses on the current state of multimodality imaging for the diagnosis and management of myocarditis and cardiac sarcoidosis, highlighting multimodality imaging approaches with practical clinical vignettes, with a discussion of knowledge gaps and future directions.

Predicting adverse cardiac events in sarcoidosis: deep learning from automated characterization of regional myocardial remodeling

Recognizing early cardiac sarcoidosis (CS) imaging phenotypes can help identify opportunities for effective treatment before irreversible myocardial pathology occurs. We aimed to characterize regional CS myocardial remodeling features correlating with future adverse cardiac events by coupling automated image processing and data analysis on cardiac magnetic resonance (CMR) imaging datasets. A deep convolutional neural network (DCNN) was used to process a CMR database of a 10-year cohort of 117 consecutive biopsy-proven sarcoidosis patients. The maximum relevance - minimum redundancy method was used to select the best subset of all the features-24 (from manual processing) and 232 (from automated processing) left ventricular (LV) structural/functional features. Three machine learning (ML) algorithms, logistic regression (LogR), support vector machine (SVM) and multi-layer neural networks (MLP), were used to build classifiers to categorize endpoints. Over a median follow-up of 41.8 (inter-quartile range 20.4-60.5) months, 35 sarcoidosis patients experienced a total of 43 cardiac events. After manual processing, LV ejection fraction (LVEF), late gadolinium enhancement, abnormal segmental wall motion, LV mass (LVM), LVMI index (LVMI), septal wall thickness, lateral wall thickness, relative wall thickness, and wall thickness of 9 (out of 17) individual LV segments were significantly different between patients with and without endpoints. After automated processing, LVEF, end-diastolic volume, end-systolic volume, LV mass and wall thickness of 92 (out of 216) individual LV segments were significantly different between patients with and without endpoints. To achieve the best predictive performance, ML algorithms selected lateral wall thickness, abnormal segmental wall motion, septal wall thickness, and increased wall thickness of 3 individual segments after manual image processing, and selected end-diastolic volume and 7 individual segments after automated image processing. LogR, SVM and MLP based on automated image processing consistently showed better predictive accuracies than those based on manual image processing. Automated image processing with a DCNN improves data resolution and regional CS myocardial remodeling pattern recognition, suggesting that a framework coupling automated image processing with data analysis can help clinical risk stratification.

RETRACTED: Association between sarcoidosis and cardiovascular Outcomes: A systematic review and Meta-analysis

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What is known?

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Previous studies showed the prevalence of cardiovascular diseases with sarcoidosis. However, there is limited data quantifying the future risks of these adverse outcomes in patients with a diagnosis of sarcoidosis.

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What is New?

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To the best of our knowledge, this is the first meta-analysis assessed the adverse cardiovascular outcomes in patients with sarcoidosis.

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Our study analyzed 22,539,096 patients and found that the incidence of Atrial Arrhythmia, Ventricular Tachycardia and Heart Failure were significantly higher in patients with sarcoidosis.

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All-cause mortality appeared to be approximately 2-fold higher in patients with sarcoidosis.

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What are the clinical implications?

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In sarcoidosis with cardiac involvement, clinicians should be aware of the increased risk of adverse cardiovascular events in these patients. Additional studies are warranted to study the optimal management approach towards patients with cardiac sarcoidosis.

Background

Sarcoidosis is a chronic inflammatory disorder of unknown etiology associated with high morbidity and mortality. Its association with cardiovascular outcomes is under-documented.

Aim

The aim of this study was to assess the adverse cardiovascular outcomes in patients with sarcoidosis compared with that of non-sarcoidosis.

Methodology

Online databases including PubMed, Embase and Scopus were queried from inception until March 2022. The outcomes assessed included all-cause mortality (ACM) and incidence of ventricular tachycardia (VT), heart failure (HF) and atrial arrhythmias (AA).

Result

A total of 6 studies with 22,539,096 participants (42,763 Sarcoidosis, 22,496,354 Non-Sarcoidosis) were included in this analysis. The pooled prevalence of sarcoidosis was 13.1% (95% CI 1% to 70%). The overall mean age was 47 years. The most common comorbidities were hypertension (12.7% vs 12.5%), and diabetes mellitus (5.5% vs 4%) respectively. The pooled analysis of primary endpoints showed that all-cause mortality (RR, 2.08; 95% CI: 1.17 to 3.08; p = 0.01) was significantly increased in sarcoidosis patients. The pooled analysis of secondary endpoints showed that the incidence of VT (RR, 15.3; 95% CI: 5.39 to 43.42); p < 0.001), HF (RR, 4.96; 95% CI: 2.02 to 12.14; p < 0.001) and AA (RR, 2.55; 95% CI: 1.47 to 4.44); p = 0.01) were significantly higher with sarcoidosis respectively compared to non-sarcoidosis.

Conclusion

Incidence of VT, HF and AA was significantly higher in patients with CS. Clinicians should be aware of these adverse cardiovascular events associated with sarcoidosis.

Performance of cardiac PET/CT with and without phase analysis for detection of scar in cardiac sarcoidosis: Comparison to cardiac magnetic resonance imaging

BACKGROUND

The presence of myocardial scar in CS patients results in poor prognosis and worse outcomes. 18F-fluorodeoxyglucose (18F-FDG) PET/CT excels at visualizing inflammation but is suboptimal at detecting scar. We evaluated PET/CT sensitivity to detect scar and investigated the incremental diagnostic value of automated PET-derived data.

METHODS

176 patients who underwent cardiac magnetic resonance (CMR) and N-13 ammonia/18F-FDG cardiac PET/CT for suspected CS within 3 months were enrolled. Scar was defined as late gadolinium enhancement (LGE) on CMR without concordant 18F-FDG uptake on 18F-FDG PET/CT. Accuracy of cardiac PET/CT at detecting scar (perfusion defect without concordant 18F-FDG uptake) was assessed before and after addition of automated PET-derived data.

RESULTS

Sensitivity of PET/CT for scar detection was 45.3% (specificity 88.9%). Addition of PET-derived LV volumes and function in a logistic regression model improved sensitivity to 57.0% (specificity: 80.0%, AUC 0.72). Addition of phase analysis maximum segmental onset of myocardial contraction > 61 improved AUC to 0.75, correctly relabeling 16.3% of patients as scar (net reclassification index 8.2%).

CONCLUSION

Sensitivity of gated PET MPI alone for scar detection in CS is suboptimal. Adding PET-derived volumes/function and phase analysis data results in improved detection and characterization of scar.

The role of multimodality imaging in patients with heart failure with reduced and preserved ejection fraction

PURPOSE OF REVIEW

The burden of clinical heart failure, both heart failure with a reduced ejection fraction (HFrEF) and with a preserved ejection fraction (HFpEF), continues to increase both nationally and globally. This review summarizes the expanding role of multimodality imaging techniques in the evaluation and management these patients.

RECENT FINDINGS

Echocardiographic assessment for heart failure continues to expand and should include a robust hemodynamic and strain assessment. Nuclear techniques have also continued to evolve and advances including computed tomography attenuation correction for single photon emission-computed tomography positron-emission tomography increase diagnostic accuracy as well as provide information such as myocardial blood flow and viability assessment. Computed tomography imaging, already well established in the assessment of coronary and valvular disease, has increasing utility in the characterization of myopathy, and cardiac magnetic resonance imaging (MRI) continues to expand its role in tissue characterization to a wider breadth of diseases, including right ventricular cardiomyopathy and left ventricle noncompaction.

SUMMARY

Although heart failure remains a clinical diagnosis based on history and examination, early imaging is critical for further assessment. Due to its widespread availability, affordability, and safety, transthoracic echocardiography has long been the mainstay tool for both initial evaluation as well as for periodic surveillance of heart failure patients, but advances in multimodality imaging are occurring at a rapid pace and promise to provide an increasing wealth of data to help manage such patients.

Quantitative Assessment of Cardiac Hypermetabolism and Perfusion for Diagnosis of Cardiac Sarcoidosis

BACKGROUND

Quantitative assessment of cardiac hypermetabolism from 18Flourodeoxy glucose (FDG) positron emission tomography (PET) may improve diagnosis of cardiac sarcoidosis (CS). We assessed different approaches for quantification of cardiac hypermetabolism and perfusion in patients with suspected CS.

METHODS AND RESULTS

Consecutive patients undergoing 18FDG PET assessment for possible CS between January 2014 and March 2019 were included. Cardiac hypermetabolism was quantified using maximal standardized uptake value (SUVMAX), cardiometabolic activity (CMA) and volume of inflammation, using relative thresholds (1.3× and 1.5× left ventricular blood pool [LVBP] activity), and absolute thresholds (SUVMAX > 2.7 and 4.1). Diagnosis of CS was established using the Japanese Ministry of Health and Wellness criteria. In total, 69 patients were studied, with definite or possible CS in 29(42.0%) patients. CMA above 1.5× LVBP SUVMAX had the highest area under the receiver operating characteristic curve (AUC 0.92). Quantitative parameters using relative thresholds had higher AUC compared to absolute thresholds (p < 0.01). Interobserver variability was low for CMA, with excellent agreement regarding absence of activity (Kappa 0.970).

CONCLUSIONS

Quantitation with scan-specific thresholds has superior diagnostic accuracy compared to absolute thresholds. Based on the potential clinical benefit, programs should consider quantification of cardiac hypermetabolism when interpreting 18F-FDG PET studies for CS.

The roles of global longitudinal strain imaging in contemporary clinical cardiology

Myocardial deformation imaging is now readily available during routine echocardiography and plays an important role in the advanced care of cardiovascular diseases. Its clinical value in detecting subtle myocardial dysfunction, by helping diagnose disease and allowing prediction of disease progression and earlier pharmacological intervention, has been demonstrated. Strain imaging has been the most studied and clinically used technique in the field of cardio-oncology. A relative percent reduction in left ventricular (LV) global longitudinal strain > 15% from baseline is considered a marker of early subclinical LV dysfunction and may have the potential to guide early initiation of cardioprotective therapy. The role of strain imaging is expanding to other fields, such as cardiac amyloidosis, other cardiomyopathies, valvular heart diseases, pulmonary hypertension, and heart failure with preserved ejection fraction. It is also used for the evaluation of the right ventricle and atria. This review aims to provide a current understanding of the roles of strain imaging in the evaluation and management of patients with cardiovascular diseases in clinical practice.

Clinical Presentation and Treatment of High-Risk Sarcoidosis

Sarcoidosis is a multisystem disease of unknown cause with heterogenous clinical manifestations and variable course. Spontaneous remissions occur in some patients while others have progressive disease impacting survival, organ function, and quality of life. Four high-risk sarcoidosis phenotypes associated with chronic inflammation have recently been identified as high-priority areas for research. These include treatment-refractory pulmonary disease, cardiac sarcoidosis, neurosarcoidosis and multiorgan sarcoidosis. Significant gaps currently exist in understanding of these high-risk manifestations of sarcoidosis, including their natural history, diagnostic criteria, biomarkers, and the treatment strategy such as the ideal agent, optimal dose and treatment duration. The use of registries with well-phenotyped patients is a critical first step to study high-risk sarcoidosis manifestations systematically. We review the diagnostic and treatment approach to high-risk sarcoidosis manifestations. Appropriately identifying these disease sub-groups will help enroll well-phenotyped patients in sarcoidosis registries and clinical trials, a necessary step to narrow existing gaps in understanding of this enigmatic disease.

Rituximab for the Treatment of Refractory Cardiac Sarcoidosis-A Single Center Experience

OBJECTIVE

To examine the effect of anti-B cell therapy (rituximab) on cardiac inflammation and function in corticosteroid-refractory cardiac sarcoidosis.

BACKGROUND

Cardiac sarcoidosis (CS) is a rare cause of cardiomyopathy characterized by granulomatous inflammation involving the myocardium. While typically responsive to corticosteroid treatment, there is a critical need for identifying effective steroid-sparing agents for disease control. Despite growing evidence on the role of B-cells in the pathogenesis of sarcoidosis, there is limited data on the efficacy of anti-B cell therapy, specifically rituximab, for controlling CS.

METHODS

We reviewed the clinical experience at a tertiary care referral center of all patients with CS who received rituximab after failing to improve with initial immunosuppression therapy, which included corticosteroids. Fluorodeoxyglucose positron emission tomography (FDG-PET/CT) images before and after rituximab treatment were evaluated. All images were interpreted by 2 experienced nuclear medicine trained physicians.

RESULTS

We identified seven patients, (5 men, 2 women; mean age at diagnosis, 49.0±7.9 years) with active cardiac sarcoidosis who were treated with rituximab. The median length of follow-up was 5.1 years. All individuals, but 1, had received prior steroid-sparing agents in addition to corticosteroids. Rituximab was administered either as 1000 mg IV x 1 or x 2 doses, separated by 2 weeks. Repeat dosing, if appropriate, was considered after 6 months. All tolerated the infusions well.Inflammation as assessed by maximum SUV on cardiac FDG PET/CT uptake significantly decreased in 6 of 7 patients (median 6.0 to 4.5, Wilcoxon signed rank z: -1.8593, W: 3), whereas left ventricular ejection fraction improved or stabilized in 4 patients but decreased in 3. Mean left ventricular ejection fraction (LVEF) was 40.1% and 43.3% before and after treatment respectively (p=0.28). Three patients reported improved physical capacity, and 5 patients showed improved arrhythmic burden on Holter monitoring or ICD interrogation. One patient subsequently developed fungal catheter-associated infection and sepsis requiring discontinuation.

CONCLUSIONS

Rituximab was well tolerated and appeared to decrease inflammation, as assessed by cardiac FDG PET/CT scan, in all but 1 patient with active CS. These data suggest that rituximab may be a promising therapeutic option for CS, which deserves further study.

Predicting risk of sudden cardiac death in patients with cardiac sarcoidosis using multimodality imaging and personalized heart modeling in a multivariable classifier

Cardiac sarcoidosis (CS), an inflammatory disease characterized by formation of granulomas in the heart, is associated with high risk of sudden cardiac death (SCD) from ventricular arrhythmias. Current "one-size-fits-all" guidelines for SCD risk assessment in CS result in insufficient appropriate primary prevention. Here, we present a two-step precision risk prediction technology for patients with CS. First, a patient's arrhythmogenic propensity arising from heterogeneous CS-induced ventricular remodeling is assessed using a novel personalized magnetic-resonance imaging and positron-emission tomography fusion mechanistic model. The resulting simulations of arrhythmogenesis are fed, together with a set of imaging and clinical biomarkers, into a supervised classifier. In a retrospective study of 45 patients, the technology achieved testing results of 60% sensitivity [95% confidence interval (CI): 57-63%], 72% specificity [95% CI: 70-74%], and 0.754 area under the receiver operating characteristic curve [95% CI: 0.710-0.797]. It outperformed clinical metrics, highlighting its potential to transform CS risk stratification.

Serum Anti-Heart and Anti-Intercalated Disk Autoantibodies: Novel Autoimmune Markers in Cardiac Sarcoidosis

Background: Sarcoidosis is an immune-mediated disease. Cardiac involvement, a granulomatous form of myocarditis, is under-recognized and prognostically relevant. Anti-heart autoantibodies (AHAs) and anti-intercalated disk autoantibodies (AIDAs) are autoimmune markers in nonsarcoidosis myocarditis forms. Objective: The aim was to assess serum AHAs and AIDAs as autoimmune markers in cardiac sarcoidosis. Methods: This is a cross-sectional study on AHA and AIDA frequency in: 29 patients (aged 46 ± 12, 20 male) with biopsy-proven extracardiac sarcoidosis and biopsy-proven or clinically suspected and confirmed by 18-fluorodeoxyglucose positron emission tomography and/or cardiovascular magnetic resonance (CMR) cardiac involvement; 30 patients (aged 44 ± 11, 12 male) with biopsy-proven extracardiac sarcoidosis without cardiac involvement (no cardiac symptoms, normal 12-lead electrocardiogram, echocardiography and CMR), and control patients with noninflammatory cardiac disease (NICD) (n = 160), ischemic heart failure (IHF) (n = 141) and normal blood donors (NBDs) (n = 270). Sarcoidosis patients were recruited in two recruiting tertiary centers in the USA and Italy. AHAs and AIDAs were detected by indirect immunofluorescence on the human myocardium and skeletal muscle. Results: AHA and AIDA frequencies were higher in sarcoidosis with cardiac involvement (86%; 62%) than in sarcoidosis without cardiac involvement (0%; 0%), NICD (8%; 4%), IHF (7%; 2%) and NBD (9%; 0%) (p = 0.0001; p = 0.0001, respectively). Sensitivity and specificity for cardiac sarcoidosis were 86% and 92% for positive AHAs and 62% and 98% for positive AIDAs, respectively. AIDAs in cardiac sarcoidosis were associated with a higher number of involved organs (p = 0.04). Conclusions: Serum AHAs and AIDAs provide novel noninvasive diagnostic autoimmune markers for cardiac sarcoidosis.

Cardiac sarcoidosis: Two case reports

The clinical presentation of cardiac sarcoidosis is variable. We report two cases of cardiac sarcoidosis to highlight the varied clinical presentations and diagnostic challenges in our setting, and encourage the consideration of sarcoidosis as a differential in unexplained arrhythmias and heart failure.

Cardiac Sarcoidosis: Pathophysiology, Diagnosis, and Management

Sarcoidosis is a chronic multi-system disorder with an unknown etiology that can affect the cardiac tissue, resulting in Cardiac Sarcoidosis (CS). The majority of these CS cases are clinically silent, and when there are symptoms, the symptoms are vague and can have a lot in common with other common cardiac diseases. These symptoms can range from arrhythmias to heart failure. If CS goes undetected, it can lead to detrimental outcomes for patients. Diagnosis depends on timely utilization of imaging modalities and non-invasive testing, while in some cases, it does necessitate biopsy. Early diagnosis and treatment with immunosuppressive agents are crucial, and it is essential that follow-up testing be performed to ensure resolution and remission. This manuscript provides an in-depth review of CS and the current literature regarding CS diagnosis and treatment.

Arrhythmia in Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) is a complex disease that can manifest as a diverse array of arrhythmias. CS patients may be at higher risk for sudden cardiac death (SCD), and, in some cases, SCD may be the first presenting symptom of the underlying disease. As such, identification, risk stratification, and management of CS-related arrhythmia are crucial in the care of these patients. Left untreated, CS carries significant arrhythmogenic morbidity and mortality. Cardiac manifestations of CS are a consequence of an inflammatory process resulting in the myocardial deposition of noncaseating granulomas. Endomyocardial biopsy remains the gold standard for diagnosis; however, biopsy yield is limited by the patchy distribution of the granulomas. As such, recent guidelines have improved clinical diagnostic pathways relying on advanced cardiac imaging to help in the diagnosis of CS. To date, corticosteroids are the best studied agent to treat CS but are associated with significant risks and limited benefits. Implantable cardioverter-defibrillators have an important role in SCD risk reduction. Catheter ablation in conjunction with antiarrhythmics seems to reduce ventricular arrhythmia burden. However, the appropriate selection of these patients is crucial as ablation is likely more helpful in the setting of a myocardial scar substrate versus arrhythmia driven by active inflammation. Further studies investigating CS pathophysiology, the pathway to diagnosis, arrhythmogenic manifestations, and SCD risk stratification will be crucial to reduce the high morbidity and mortality of this disease.

Sarcoid Heart Disease: an Update on Diagnosis and Management

PURPOSE OF REVIEW

The purpose of this review is to provide an update on cardiac sarcoidosis (CS) and to discuss the current recommendations and progress in diagnosis and management of this disease. Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Cardiac involvement is seen in at least 25% and is associated with poor prognosis. Manifestations of cardiac sarcoidosis (CS) can vary from presence of silent myocardial granulomas, which may lead to sudden death, to symptomatic conduction abnormalities, ventricular arrhythmias, and heart failure.

RECENT FINDINGS

We discuss newer imaging modalities such as cardiac magnetic resonance imaging and positron emission tomography in conjunction with clinical criteria increasingly used for diagnosing and prognosticating patients with CS. Immunosuppression (primarily corticosteroids) is recommended for treatment of CS; however, its efficacy has never been proven in prospective randomized studies. The role of imaging to guide the use of immunotherapy is unknown. Cardiac sarcoidosis continues to challenge clinicians due to its protean presentations, lack of diagnostic standards, and data for risk stratification and treatment. There is a need for prospective, randomized controlled trials to understand how best to diagnose and treat cardiac sarcoidosis.

Screening Sarcoidosis Patients for Occult Disease

As sarcoidosis may involve any organ, sarcoidosis patients should be evaluated for occult disease. Screening for some organ involvement may not be warranted if it is unlikely to cause symptoms, organ dysfunction, or affect clinical outcome. Even organ involvement that affects clinical outcome does not necessarily require screening if early detection fails to change the patient's quality of life or prognosis. On the other hand, early detection of some forms of sarcoidosis may improve outcomes and survival. This manuscript describes the approach to screening sarcoidosis patients for previously undetected disease. Screening for sarcoidosis should commence with a meticulous medical history and physical examination. Many sarcoidosis patients present with physical signs or symptoms of sarcoidosis that have not been recognized as manifestations of the disease. Detection of sarcoidosis in these instances depends on the clinician's familiarity with the varied clinical presentations of sarcoidosis. In addition, sarcoidosis patients may present with symptoms or signs that are not related to specific organ involvement that have been described as parasarcoidosis syndromes. It is conjectured that parasarcoidosis syndromes result from systemic release of inflammatory mediators from the sarcoidosis granuloma. Certain forms of sarcoidosis may cause permanent and serious problems that can be prevented if they are detected early in the course of their disease. These include (1) ocular involvement that may lead to permanent vision impairment; (2) vitamin D dysregulation that may lead to hypercalcemia, nephrolithiasis, and permanent kidney injury; and (3) cardiac sarcoidosis that may lead to a cardiomyopathy, ventricular arrhythmias, heart block, and sudden death. Screening for these forms of organ involvement requires detailed screening approaches.

Indirect pathological indicators for cardiac sarcoidosis on endomyocardial biopsy

BACKGROUND

The definitive pathologic diagnosis of cardiac sarcoidosis requires observation of a granuloma in the myocardial tissue. It is common, however, to receive a "negative" report for a clinically probable case. We would like to advise pathologists and clinicians on how to interpret "negative" biopsies.

METHODS

Our study samples were 27 endomyocardial biopsies from 25 patients, three cardiac transplantation and an autopsied heart with suspected cardiac sarcoidosis. Pathologic, radiologic, and clinical features were compared.

RESULTS

The presence of micro-granulomas or increased histiocytic infiltration was always (6/6 or 100%) associated with fatty infiltration and confluent fibrosis, and they showed radiological features of sarcoidosis. Three of five cases (60%) with fatty change and confluent fibrosis were probable for cardiac sarcoidosis on radiology. When either confluent fibrosis or fatty change was present, one-third (3/9) were radiologically probable for cardiac sarcoidosis. We interpreted cases with micro-granuloma as positive for cardiac sarcoidosis (five of 25, 20%). Cases with both confluent fibrosis and fatty change were interpreted as probable for cardiac sarcoidosis (seven of 25, 28%). Another 13 cases, including eight cases with either confluent fibrosis or fatty change, were interpreted as low probability based on endomyocardial biopsy.

CONCLUSIONS

The presence of micro-granuloma could be an evidence for positive diagnosis of cardiac sarcoidosis. Presence of both confluent fibrosis and fatty change is necessary for probable cardiac sarcoidosis in the absence of granuloma. Either of confluent fibrosis or fatty change may be an indirect pathological evidence but they are interpreted as nonspecific findings.

Clinical Presentations, Pathogenesis, and Therapy of Sarcoidosis: State of the Art

Sarcoidosis is a systemic disease of unknown etiology characterized by the presence of noncaseating granulomas that can occur in any organ, most commonly the lungs. Early and accurate diagnosis of sarcoidosis remains challenging because initial presentations may vary, many patients are asymptomatic, and there is no single reliable diagnostic test. Prognosis is variable and depends on epidemiologic factors, mode of onset, initial clinical course, and specific organ involvement. From a pathobiological standpoint, sarcoidosis represents an immune paradox, where an excessive spread of both the innate and the adaptive immune arms of the immune system is accompanied by a state of partial immune anergy. For all these reasons, the optimal treatment for sarcoidosis remains unclear, with corticosteroid therapy being the current gold standard for those patients with significantly symptomatic or progressive pulmonary disease or serious extrapulmonary disease. This review is a state of the art of clinical presentations and immunological features of sarcoidosis, and the current therapeutic approaches used to treat the disease.

The Multi-modality Cardiac Imaging Approach to Cardiac Sarcoidosis

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.

Review: Contrast-enhanced magnetic resonance in the diagnosis and management of cardiac sarcoidosis

Sarcoidosis is a relatively rare inflammatory condition which potentially carries high morbidity and substantial mortality. Due to the fact that it does not subject patients to ionizing radiation, has high temporal, spatial and contrast resolutions, cardiovascular magnetic resonance imaging (CMR) has become an important diagnostic and prognostic modality in the evaluation for cardiac involvement in this condition. This review provides relevant clinical and pathophysiological background on cardiac sarcoidosis, whilst detailing the role of CMR imaging in the diagnosis, and management of this condition.

Myocarditis in the Athlete: Arrhythmogenic Substrates, Clinical Manifestations, Management, and Eligibility Decisions

Myocarditis is as an important cause of sudden cardiac death (SCD) among athletes. The incidence of SCD ascribed to myocarditis did not change after the introduction of pre-participation screening in Italy, due to the transient nature of the disease and problems in the differential diagnosis with the athlete's heart. The arrhythmic burden and the underlying mechanisms differ between the acute and chronic setting, depending on the relative impact of acute inflammation versus post-inflammatory myocardial fibrosis. In the acute phase, ventricular arrhythmias vary from isolated ventricular ectopic beats to complex tachycardias that can lead to SCD. Atrioventricular blocks are typical of specific forms of myocarditis, and supraventricular arrhythmias may be observed in case of atrial inflammation. Athletes with acute myocarditis should be temporarily restricted from physical exercise, until complete recovery. However, ventricular tachycardia may also occur in the chronic phase in the context of post-inflammatory myocardial scar.

The Many Faces of Cardiac Sarcoidosis

OBJECTIVES

The objective of this study was to review and illustrate the sometimes diagnostically challenging features of cardiac sarcoidosis. We emphasize variable phenotypes presented at explant and biopsy evaluation and review literature regarding ancillary clinical and pathologic studies to enhance diagnostic accuracy.

METHODS

A literature review was performed and two cardiac sarcoidosis cases were illustrated.

RESULTS

Our cases and literature review demonstrate the pathologic spectrum of cardiac sarcoidosis. Irregular left ventricular free wall involvement is most common, followed by the interventricular septum and right ventricle. Although granulomas are often composed of tight epithelioid macrophage aggregates, early granulomas comprise loosely associated macrophages with lymphocyte predominance. Chronic disease leads to fibrosis and end-stage heart failure. Sampling errors and variable histology cause low endomyocardial biopsy sensitivity.

CONCLUSIONS

Current guidelines use clinical, radiologic, and immunohistologic criteria for diagnosing cardiac sarcoidosis. Knowledge of these guidelines will assist pathologists in making accurate diagnosis of this disease.

Regional Myocardial Remodeling Characteristics Correlates With Cardiac Events in Sarcoidosis

BACKGROUND

The poor prognosis of cardiac sarcoidosis (CS) underscores the need for risk stratification.

PURPOSE

To investigate the prognostic significance of ventricular/myocardial remodeling features in sarcoidosis.

STUDY TYPE

Retrospective.

POPULATION

In all, 132 biopsy-proven sarcoidosis patients imaged from 2008 to 2018. The primary endpoint was a composite of cardiac mortality, new onset arrhythmias, hospitalization for heart failure, and device implantation.

FIELD STRENGTH/SEQUENCE

No field strength or sequence restrictions.

ASSESSMENT

Global and regional ventricular/myocardial remodeling features were assessed by standard volumetric measurements and automated function imaging postprocessing analysis.

STATISTICAL TESTS

Student's t-test or Mann-Whitney test (chi² test or Fisher's exact test for categorical variables) were used for comparisons. Cox-proportional hazards regression model, univariate /multivariate analyses, and receiver operating characteristic were performed to relate clinical/lab data, imaging parameters to the endpoints.

RESULTS

Over a median follow-up of 40.7 (interquartile range 18.8-60.5) months, 41 (31.1%) patients developed adverse cardiac events. Abnormal left ventricular (LV) geometric remodeling alterations (measured by LV mass index and relative wall thickness) occurred 3.66-fold more frequently in patients with endpoints than patients without. The ratio of patients with endpoints increased as ventricular remodeling phenotype progressed. In patients with endpoints, regional myocardial wall thickness (RMWT) was significantly (P = 0.022) increased in six clustered LV segments located in the middle interventricular septum and basal/middle anterolateral walls. In all of the abnormal ventricular remodeling stages, patients with endpoints constantly had higher mean RMWT than those without. Among clinical, electrocardiographic, and imaging parameters, LV mass index (hazard ratio [HR] 1.010 95% confidence interval [CI] 1.002-1.018, P = 0.017) and mean RMWT (HR 3.482 95% CI 1.679-7.223, P = 0.001) were independently associated with endpoints. Sarcoidosis patients without this RMWT distribution pattern were significantly (P < 0.001) more likely to be free of the occurrence of subsequent cardiac events.

DATA CONCLUSION

Regional myocardial remodeling characteristics are associated with subsequent adverse cardiac events in sarcoidosis.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY STAGE: 2 J. Magn. Reson. Imaging 2020;52:499-509.

Myocardial Positron Emission Tomography for Evaluation of Cardiac Sarcoidosis: Specialized Protocols for Better Diagnosis

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology with various clinical presentations depending on the organs involved. Since cardiac sarcoidosis (CS) portends a higher risk of morbidity and mortality, early diagnosis and aggressive medical treatment are essential to improve the prognosis. ¹⁸F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) has emerged as an important tool with practical advantages in assessing disease activity and monitoring the treatment response in patients with CS. While it has high sensitivity, it also has great variability in specificity, probably due to normal physiologic myocardial FDG uptake, which interferes with the evaluation and follow-up of CS using FDG-PET. This review details the technical aspects of FDG-PET imaging for evaluating and diagnosing CS, assessing disease activity, and monitoring therapeutic response.

Clinical Manifestations, Diagnosis, and Treatment of Sarcoidosis

The focus of this review is current knowledge about the epidemiology, clinical manifestations, diagnosis, and treatment of both pulmonary sarcoidosis and extrapulmonary sarcoidosis. Although intrathoracic involvement is the hallmark of the disease, present in over 90% of patients, sarcoidosis can affect virtually any organ. Clinical presentations of sarcoidosis are diverse, ranging from asymptomatic, incidental findings to organ failure. Diagnosis requires the presence of noncaseating granuloma and compatible presentations after exclusion of other identifiable causes. Spontaneous remission is frequent, so treatment is not always indicated unless the disease is symptomatic or causes progressive organ damage/dysfunction. Glucocorticoids are the cornerstone of treatment of sarcoidosis even though evidence from randomized controlled studies is lacking. Glucocorticoid-sparing agents and biologic agents are often used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects.

Echocardiography in Infiltrative Cardiomyopathy

Left ventricular (LV) wall thickening can occur due to both physiological and pathological processes. Some LV wall thickening is caused by infiltrative cardiac deposition diseases - rare disorders from both inherited and acquired conditions, with varying systemic manifestations. They portend a poor prognosis and are generally not reversible except in rare circumstances when early diagnosis and treatment may alter the outcome (e.g., Fabry disease). Cardiac involvement is variable and depends on the degree of infiltration and type of infiltrate. These changes often lead to the development of abnormalities in both the relaxation and contractile function of the heart ultimately resulting in heart failure. Echocardiography is generally the first investigation of choice as it is easily available and gives valuable information about the thickness of the ventricular walls as well as systolic and diastolic function. It is also able to identify unique, characteristic features of the disease as well as detecting any haemodynamic sequelae. This review looks at the role of echocardiography in the diagnosis and prognosis of infiltrative cardiac deposition diseases.

Cardiac sarcoidosis: Case presentation and Review of the literature

Cardiac sarcoidosis usually occurs in the context of systemic disease; however, isolated cardiac involvement can occur in up to 25% of cases and tends to be clinically silent. When symptoms are present, they are often nonspecific and occasionally fatal, representing a diagnostic challenge. A high index of clinical suspicion and the integration of appropriate imaging, laboratory, and pathologic findings is always required. Treatment aims to control the systemic inflammatory condition while preventing further cardiac damage. However, even with adequate diagnosis and treatment strategies, prognosis remains poor. We describe the case of a patient who presented with cardiac symptoms, whose initial examination was unrevealing. Diagnosis was made retrospectively based on later systemic manifestations that revealed characteristic sarcoidosis findings.