Treatment of heart block due to sarcoid heart disease

Exercise test in patients with sarcoidosis. The importance of repolarization disturbances

The study population comprises 28 patients with sarcoidosis who all had repolarization disturbances in their exercise ECGs. None of the patients had hypertension or known cardiovascular disease, and all but two were non-smokers. The mean age was 45 years. Exercise test with beta-adrenergic blockade was performed within one month of the first examination. Persisting abnormal ST-T changes in exercise ECGs after beta-blockade were seen in 12 (43%) patients. No significant relationship was found between persisting ST-T changes and age, sex, chest X-ray stage, lung function or working capacity. In an earlier study, we found ST-T abnormalities in exercise ECG in 56 of 127 individuals (44%) in a consecutive 5-year study of patients with newly detected sarcoidosis. From this and the present report we postulate that, in our region, as much as 20% of the patients with newly detected sarcoidosis might have organic myocardial disease, possibly of sarcoid origin, as shown by repolarization disturbances in exercise ECG. If ECG abnormalities in the ST-T region are present in patients with sarcoidosis, exercise ECG with beta-blockade is a simple way of establishing suspicion of organic myocardial lesions. If exercise ECG abnormalities in the ST-T region persist after beta-blockade, careful clinical follow-up is recommended, and, in some patients early steroid therapy should be considered.

Cardiopulmonary function in sarcoidosis

Hemodynamics, angiocardiographic findings and lung function were evaluated in 10 patients with clinically, radiologically and histopathologically established sarcoidosis. All 10 patients had cardiac symptoms and/or abnormal ECG. Right and left heart catheterization, angiocardiography, spirometry and diffusion capacity were performed in all patients. Pulmonary hypertension was present in the two patients with stage III sarcoidosis and in 7 of 8 patients with stages I and II. Right ventricular end-diastolic pressure was elevated in 6 patients. Seven patients had findings compatible with a failing left ventricle with elevated end-diastolic pressure and/or elevated pulmonary capillary wedge pressure. None of the patients had entirely normal hemodynamic findings. Angiocardiography showed a low ejection fraction in 6 patients but no wall asynergy. Right ventricular angiography and coronary angiography were normal in all patients. Findings compatible with failure of the left and right ventricle of the heart was common in our sarcoid patients with cardiac symptoms and/or abnormal ECG. Impairment of the pulmonary function does not seem to be the only reason for the hemodynamic findings, thus indicating the possibility of myocardial sarcoidosis.

Relationship between arrhythmogenesis and disease activity in cardiac sarcoidosis

BACKGROUND

In patients with cardiac sarcoidosis, ventricular arrhythmias and/or conduction disturbances are frequently observed and sometimes fatal. However, few reports on disease activity and arrhythmic events in cardiac sarcoidosis are available.

OBJECTIVE

The purpose of this study was to investigate the relationship between disease activity and arrhythmic events in cardiac sarcoidosis and the effect of corticosteroid therapy.

METHODS

The study population consisted of 15 cardiac sarcoidosis patients with new-onset symptomatic arrhythmia, including eight patients admitted once for complete atrioventricular block (CAVB), five patients admitted once for sustained ventricular tachycardia (VT), and two patients admitted twice for two arrhythmic events (one for CAVB and the other for sustained VT). Disease activity was evaluated by gallium-67 citrate (Ga) scintigraphy. All patients with positive Ga uptake were treated with corticosteroids, and arrhythmic events were evaluated by repeat Holter recordings.

RESULTS

Positive uptake of Ga was observed in 8 (80%) of the 10 CAVB events and in 1 (14%) of the 7 sustained VT events (80% vs 14%, P = .02). Corticosteroids abolished myocardial Ga uptake in all nine patients with positive Ga uptake. After corticosteroid therapy was started, AV conduction improved in 5 of 9 CAVB patients (including 8 patients with new-onset CAVB and one patient with history of CAVB). However, ventricular arrhythmias were not improved after corticosteroid therapy.

CONCLUSION

In cardiac sarcoidosis patients, CAVB develops mainly during the active phase of the disease. Early treatment with corticosteroids might improve AV conduction disturbance. However, sustained VT is not closely linked with disease activity and frequently develops in the advanced stage of disease.

Sarcoid heart disease: clinical course and treatment

Sarcoidosis is a rare granulomatous disease of unknown etiology that can affect any organ. Cardiac involvement, although uncommon, has a wide spectrum of clinical manifestations and is potentially fatal. Although there is no agreement upon a strategy for the diagnosis (which is difficult to make based on clinical information alone), the introduction of newer technology is promising and may be useful both for the early diagnosis of cardiac involvement and for the evaluation of response to therapy. Early treatment is crucial in improving symptoms and prognosis. ICD implantation and cardiac transplantation may offer improvements in management, as steroid therapy and pacemaker implantation has led to improved outcomes over the past three decades.

Incidence of cardiac sarcoidosis in Japanese patients with high-degree atrioventricular block

In Japan the majority of sarcoidosis-related deaths are due to cardiac sarcoidosis. One of the most common electrocardiographic abnormalities in patients with this disease is atrioventricular block. This study surveyed the incidence of cardiac sarcoidosis in Japanese patients (40 men and 49 women; mean age, 69.1 years) with high-degree atrioventricular block who were admitted to the hospital to receive a permanent pacemaker. We excluded cases in which sarcoidosis had been diagnosed from the involvement of other organs. Patients with the characteristic signs of sarcoidosis underwent echocardiography, radionuclide imaging, and biopsy. Ten cases (11.2%) of cardiac sarcoidosis were diagnosed, most frequently in women aged 40 to 69 years (8 of 25, 32%). Thus the possibility of cardiac sarcoidosis should be carefully considered in middle-aged or elderly Japanese women who show high-degree atrioventricular block.

Cardiac sarcoidosis: diagnostic, prognostic, and therapeutic considerations

Cardiac involvement in patients with sarcoidosis is an important consideration for those who are concerned with this strange disease. Sarcoidosis is not an acute malignant disease but may be noticed at the time of sudden, expected death as fatal myocardial sarcoidosis at autopsy. Even with modern advances in our ability to diagnose heart disease, cardiac sarcoidosis is still often overlooked because of its subclinical disease progression. In view of this, an extensive review of previously published literature and of our own case analyses has been carried out because of the authors' long-term experience with performing Konno's endomyocardial biopsy, which was originally developed in 1962 at the author's institution. However, the sensitivity of endomyocardial biopsy in detecting sarcoid granuloma is low (20-30%), and, instead, various kinds of nongranulomatous pathologies are often seen. During the course of our research it was found that there might exist a racial difference in cardiac sarcoidosis. Cardiac death was much more frequent in Japanese patients. The possibility that heart disease in sarcoidosis is caused by cor pulmonale due to advanced pulmonary fibrosis should be reevaluated because only a limited amount of background data is available. The author's review clarified the fact that cardiac sarcoidosis is caused by myocardial or pericardial involvement, resulting in various kinds of bradyarrhythmias or tachyarrhythmias and/or congestive heart failure. Electrocardiographic (ECG) and Holter monitor readings provide a simple and effective method for early detection of this disease. The incidence of ECG abnormalities in a total of 963 sarcoidosis patients was 22.1%, which was more frequent than that of the sex- and age-matched healthy control subjects (17.9%; p < 0.025). Echocardiography and radionuclide studies also provide useful clinical information. Careful follow-up and early corticosteroid administration followed by small maintenance doses may prevent the progression of the disease and improve prognosis. Owing to the progress in antiarrhythmic drugs and pacemaker implantation, the primary cause of death in cardiac sarcoidosis has changed from sudden death (1976 report) to congestive heart failure (1985 report).

Sarcoidosis of the heart

Myocardial involvement in sarcoidosis occurs in about 27% of patients. Clinical manifestations include ventricular arrhythmias, conduction abnormalities, and sudden death. Diagnosis requires clinical suspicion and may be supported by electrocardiography, echocardiography, thallium imaging, gallium-67 scanning, and myocardial biopsy. Steroids seem to be beneficial in the treatment of myocardial sarcoidosis. Those who do not respond to medical treatment may benefit from cardiac transplantation.

Clinical study on cardiac sarcoidosis

Forty-one patients with sarcoidosis were investigated for cardiac involvement. The results are summarized as follows: The focal left ventricular perfusion defect was found on the TMPS's of 5 out of 41 patients with sarcoidosis. The defect disappeared in four of these five patients over a 3-year period, but remained in the patient with fatal myocardial sarcoidosis. A decreased left ventricular ejection fraction was found in 14 out of 41 patients with sarcoidosis, and in 3 out of 5 patients with the left ventricular perfusion defect. Echocardiographic examination did not reveal left ventricular wall dysfunction at the site of the left ventricular perfusion defect, except in one patient with fatal myocardial sarcoidosis. Holter ECG's showed such abnormalities as CRBBB, heart blocks, PVC, and PSC in 13 out of 32 patients with sarcoidosis. SACE activity was elevated in all three patients with the left ventricular perfusion defect that were examined, and it could be correlated with changes in the left ventricular perfusion defect in one of them.

Systemic sarcoidosis and electrocardiographic conduction abnormalities. Electrophysiologic evaluation of two patients

Two patients with long histories of sarcoidosis had progression of conduction abnormalities to heart block and severe bradycardia. Conduction system involvement was trifascicular in both patients, though evidence for left ventricular functional impairment was otherwise lacking. Sudden death is seen more commonly in patients with sarcoidosis who have diffuse myocardial involvement, while conduction abnormalities can occur with relatively localized disease.