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Palvia AR, Kaur A, Azeez GA, Thirunagari M, Fatima N, Anand A, Nassar ST. Current Practices and Emerging Therapies to Optimize Heart Failure Management in Cardiac Sarcoidosis: A Systematic Review. Cureus 2024; 16:e66515. [PMID: 39252727 PMCID: PMC11381125 DOI: 10.7759/cureus.66515] [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: 07/25/2024] [Accepted: 08/09/2024] [Indexed: 09/11/2024] Open
Abstract
Cardiac sarcoidosis (CS) is a distinctive manifestation of sarcoidosis, a multisystemic inflammatory disorder that is characterized by non-necrotizing granulomas. CS can lead to arrhythmias, heart failure (HF), and sudden cardiac death. The diagnosis of CS involves imaging in the form of a two-dimensional echocardiogram, cardiac magnetic resonance imaging (MRI), an 18-fluoro-deoxyglucose positron emission tomography (FDG-PET) scan, and an endomyocardial biopsy. Treatment of CS entails corticosteroids, immunosuppressive agents, monoclonal antibodies, and, in advanced cases, heart transplantation (HTx). This systematic review follows Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, focusing on HF in sarcoidosis patients. Eligibility criteria include recent (2019-2024) research papers on sarcoidosis-induced heart failure, excluding other causes. The databases searched were PubMed, Google Scholar, and ScienceDirect. From 36,755 initial articles, 2,060 remained after filtering, and 17 were selected for quality assessment. Based on quality assessment, 11 studies were included in the final review. In CS, a variety of treatment strategies can be implemented. Corticosteroids are the first-line therapeutic options, and in the majority of cases, they are very successful in controlling the disease progression. Immunosuppressive agents like methotrexate and azathioprine are used to avoid long-term steroid use. Both corticosteroids and immunosuppressives act by reducing inflammation and preventing myocardial scarring. Biological agents like infliximab and adalimumab prevent disease progression by targeting specific inflammatory pathways and are used in refractory cases. Regular HF management drugs like angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), sodium-glucose transport protein 2 (SGLT2) inhibitors, beta-blockers, and diuretics help in optimizing cardiac function. In severe cases, a left ventricular assist device (LVAD) may be required. The ultimate treatment for end-stage CS is HTx, which has to be supplemented with a strong, individualized regimen of glucocorticoids and immunosuppressives to avoid graft rejection and to control sarcoidosis. Due to a lack of standard protocols for management and limited knowledge about CS, the ideal treatment of HF is still a matter of debate. Hence, further research and clinical trials need to be performed to optimize patient outcomes.
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Affiliation(s)
- Aadi R Palvia
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Avneet Kaur
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Gibran A Azeez
- Pathophysiology, St George's University, St George's, GRD
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | | | - Nazeefa Fatima
- Clinical Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Abhinav Anand
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Sondos T Nassar
- Medicine and Surgery, Jordan University of Science and Technology, Amman, JOR
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Ribeiro Neto ML, Jellis CL, Cremer PC, Harper LJ, Taimeh Z, Culver DA. Cardiac Sarcoidosis. Clin Chest Med 2024; 45:105-118. [PMID: 38245360 DOI: 10.1016/j.ccm.2023.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2024]
Abstract
Cardiac involvement is a major cause of morbidity and mortality in patients with sarcoidosis. It is important to distinguish between clinical manifest diseases from clinically silent diseases. Advanced cardiac imaging studies are crucial in the diagnostic pathway. In suspected isolated cardiac sarcoidosis, it's key to rule out alternative diagnoses. Therapeutic options can be divided into immunosuppressive agents, guideline-directed medical therapy, antiarrhythmic medications, device/ablation therapy, and heart transplantation.
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Affiliation(s)
- Manuel L Ribeiro Neto
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA.
| | - Christine L Jellis
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Paul C Cremer
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Logan J Harper
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA
| | - Ziad Taimeh
- Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Daniel A Culver
- Department of Pulmonary Medicine, Cleveland Clinic, 9500 Euclid Avenue / A90, Cleveland, OH 44195, USA
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Sink J, Joyce C, Liebo MJ, Wilber DJ. Long-Term Outcomes of Cardiac Sarcoid: Prognostic Implications of Isolated Cardiac Involvement and Impact of Diagnostic Delays. J Am Heart Assoc 2023; 12:e028342. [PMID: 37750587 PMCID: PMC10727252 DOI: 10.1161/jaha.122.028342] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 09/06/2023] [Indexed: 09/27/2023]
Abstract
Background Isolated cardiac sarcoid (iCS) is reported to have more severe clinical presentation and greater risk of adverse events compared with cardiac sarcoid (CS) with extracardiac involvement (nonisolated CS). Delays in diagnosing specific organ involvement may play a role in these described differences. Methods and Results A retrospective observational study of patients with CS over a 20-year period was conducted. Objective evidence of organ involvement and time of onset based on consensus criteria were identified. CS was confirmed by histology in all patients from myocardium only (iCS) or extracardiac tissue (nonisolated CS). The primary end point was a composite of mortality, orthotopic heart transplant, and durable left ventricular assist device implantation. CS was isolated in 9 of 50 patients (18%). Among baseline characteristics, iCS and nonisolated CS differed significantly only in the frequency of sustained ventricular tachycardia at presentation (78% versus 37%; P=0.03) and delay in CS diagnosis >6 months (67% versus 5%; P<0.01). A nonsignificant trend toward lower left ventricular ejection fraction and more frequent heart failure in iCS was observed. Over a median follow-up of 9.7 years (95% CI, 6.8-10.8), 18 patients reached the primary end point (13 deaths, 2 orthotopic heart transplants, and 3 durable left ventricular assist device implantations). The 1-, 5-, and 10-year event-free survival rates were 96% (95% CI, 85%-99%), 79% (95% CI, 64%-88%), and 58% (95% CI, 40%-73%), respectively, without differences between groups. There were no significant predictors of the primary end point, including delayed CS diagnosis. Conclusions Long-term outcomes were similar between iCS and nonisolated CS in patients with histologically documented sarcoid. Diagnostic delays may contribute to differences in the dominant clinical presentation, despite similar outcomes.
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Affiliation(s)
- Joshua Sink
- Loyola University Chicago Stritch School of MedicineMaywoodILUSA
- Present address:
Department of MedicineNorthwestern UniversityChicagoILUSA
| | - Cara Joyce
- Department of MedicineLoyola University of Chicago Stritch School of MedicineMaywoodILUSA
| | - Max J. Liebo
- Section of Advanced Heart Failure, Division of Cardiology, Department of MedicineLoyola University Chicago Stritch School of MedicineMaywoodILUSA
| | - David J. Wilber
- Department of MedicineLoyola University of Chicago Stritch School of MedicineMaywoodILUSA
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Inglis SS, Thomas SC, Bois MC, Rosenbaum AN. Case Series: Recurrence of Cardiac Sarcoidosis After Orthotopic Heart Transplantation. Transplant Proc 2023; 55:1688-1691. [PMID: 37407375 DOI: 10.1016/j.transproceed.2023.03.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 02/23/2023] [Accepted: 03/30/2023] [Indexed: 07/07/2023]
Abstract
Orthotopic heart transplantation for cardiac sarcoidosis (CS) is becoming increasingly common. Historically, there have been concerns regarding disease recurrence within the allograft. Although rarely reported in the literature, cases of recurrent CS tend to be observed in patients after dose reduction of immunosuppressive therapy and cessation of corticosteroids. Here, we present 2 cases of recurrent CS after orthotopic heart transplantation, confirmed on endomyocardial biopsy. Case 1 reports a 50-year-old man with a fulminant course of giant cell myocarditis who developed allograft recurrence with granulomas 5 years after transplantation despite maintenance corticosteroid therapy. Case 2 reports a 47-year-old man with CS who developed recurrence with the presence of giant cells 2 years after transplantation, with a benign clinical course. With these cases, we demonstrate the clinical overlap between CS and giant cell myocarditis and highlight the spectrum of the disease process. We also demonstrate that CS can recur despite corticosteroid maintenance therapy.
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Affiliation(s)
- Sara S Inglis
- Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
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Buttar C, Lakhdar S, Pavankumar T, Guzman-Perez L, Mahmood K, Collura G. Heart transplantation in end-stage heart failure secondary to cardiac sarcoidosis: an updated systematic review. Heart Fail Rev 2023; 28:961-966. [PMID: 36355274 DOI: 10.1007/s10741-022-10284-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/25/2022] [Indexed: 11/11/2022]
Abstract
The prevalence of cardiac sarcoidosis is increasing with improved cardiac imaging and may lead to severe heart failure, cardiomyopathy, and arrhythmias that warrant heart transplant consideration. This study aimed to evaluate the outcomes of heart transplantation in sarcoidosis. We systematically searched PubMed/MEDLINE, EMBASE and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines. We identified 15 articles that examined patients with cardiac sarcoidosis. The study aimed to evaluate the outcomes of heart transplantation in cardiac sarcoidosis. We systematically searched EMBASE, PubMed/MEDLINE, and Cochrane Library following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. We identified 15 studies that examined 1075 patients with cardiac sarcoidosis who underwent heart transplantation. A total of five studies reported individual patient data. Forty-two patients have been pooled for further analysis. There were 22 male patients, 14 female patients, and 7 patients whose gender was not reported. Among these patients, 10 patients had concomitant pulmonary sarcoidosis at the time of diagnosis. The mean survival was reported for all 42 patients. The mean survival in months was 71.4 months, with a range of 2 days to 288 months. Three patients died of graft failure, 2 patients from septic shock, 2 patients from pneumonia, 1 patient from cervical cancer, and 1 patient from sudden cardiac death. One patient developed a malignant arrythmia in the setting of CMV myocarditis post-heart transplant. Sarcoidosis recurrence after heart transplant was reported in 3 of 30 patients..Patients with cardiac sarcoidosis have shown to have favorable outcomes after heart transplant. Despite these outcomes, some centers still hesitate to pursue heart transplant for CS patients. Carefully selected patients with advanced-stage heart failure due to cardiac sarcoidosis have encouraging outcomes after transplantation. Further studies will be needed to evaluate the outcomes of heart transplantation in sarcoidosis.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane Hospital, New Orleans, LA, USA
| | - Sofia Lakhdar
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, USA.
| | - Thota Pavankumar
- Department of Cardiology, Ochsner Medical Center, New Orleans, LA, USA
| | - Laura Guzman-Perez
- Department of Medicine, Icahn School of Medicine at Mount Sinai/NYC H+H/Queens, Queens, NY, USA
| | - Kiran Mahmood
- Department of Heart Failure and Transplant, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giovina Collura
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, NYC H+H/Queens, Queens, NY, USA
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Ghodsizad A. Cardiac transplantation as surgical treatment for cardiac sarcoidosis. J Card Surg 2021; 36:4245-4246. [PMID: 34227699 DOI: 10.1111/jocs.15780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/20/2021] [Accepted: 06/21/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Ali Ghodsizad
- Department of Surgery, Division Thoracic Transplantation and MCS, Miami Transplant Institute, University of Miami, Miami, Florida, USA
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