Prevalence of cardiac sarcoidosis in white population: a case-control study: Proposal for a novel risk index based on commonly available tests

Screening for cardiac sarcoidosis: diagnostic approach and long-term follow-up in a tertiary centre

BACKGROUND

Cardiac sarcoidosis (CS) is associated with poor prognosis, making early diagnosis and treatment important. This study evaluated the results of a diagnostic approach in patients with known sarcoidosis and suspected cardiac involvement in a tertiary centre and their long-term outcomes.

METHODS

We included 180 patients with sarcoidosis and a clinical suspicion of CS. In addition to an electrocardiogram (ECG)/transthoracic echocardiogram (TTE), cardiovascular magnetic resonance imaging (CMR) and positron emission tomography (PET) were performed in 66% and 37% of the patients, respectively. The diagnosis of CS was based on the Heart Rhythm Society criteria. Follow-up was performed, and a composite endpoint of sustained ventricular tachycardia, ventricular fibrillation, aborted sudden cardiac death, heart failure hospitalisation, heart transplantation or cardiac death was used for the survival analysis.

RESULTS

Symptoms were present in 87% of the patients, and ECG/TTE abnormalities were found in 92/180 patients (51%). Using CMR and/or PET, 31/92 patients (34%) were diagnosed with CS. In 15 patients, an alternative diagnosis was found. CS was diagnosed in 11/88 patients (13%) without ECG/TTE abnormalities. During a median follow-up time of 4.4 years (interquartile range: 2.3-6.8), 11 composite endpoints occurred, more frequently in CS patients than in sarcoidosis patients without cardiac involvement (p < 0.001). Patients with ECG/TTE abnormalities at baseline had worse outcomes than those without abnormalities (p = 0.019).

CONCLUSION

CS was diagnosed in 23% of the referred sarcoidosis patients. ECG/TTE were of limited diagnostic value for screening for CS but seemed to have important prognostic value as patients with normal ECG/TTE results who did meet the diagnostic CS criteria had a very good prognosis. CMR/PET provided a good diagnostic yield and identified other cardiac diseases.

A framework for exclusion of alternative diagnoses in sarcoidosis

Sarcoidosis is a multisystem granulomatous syndrome that arises from a persistent immune response to a triggering antigen(s). There is no "gold standard" test or algorithm for the diagnosis of sarcoidosis, making the diagnosis one of exclusion. The presentation of the disease varies substantially between individuals, in both the number of organs involved, and the manifestations seen in individual organs. These qualities dictate that health care providers diagnosing sarcoidosis must consider a wide range of possible alternative diagnoses, from across a range of presentations and medical specialties (infectious, inflammatory, cardiac, neurologic). Current guideline-based diagnosis of sarcoidosis recommends fulfillment of three criteria: 1) compatible clinical presentation and/or imaging 2) demonstration of granulomatous inflammation by biopsy (when possible) and, 3) exclusion of alternative causes, but do not provide guidance on standardized strategies for exclusion of alternative diagnoses. In this review, we provide a summary of the most common differential diagnoses for sarcoidosis involvement of lung, eye, skin, central nervous system, heart, liver, and kidney. We then propose a framework for testing to exclude alternative diagnoses based on pretest probability of sarcoidosis, defined as high (typical findings with sarcoidosis involvement confirmed in another organ), moderate (typical findings in a single organ), or low (atypical/findings suggesting of an alternative diagnosis). This work highlights the need for informed and careful exclusion of alternative diagnoses in sarcoidosis.

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.

Sarcoid heart disease and imaging

Cardiac sarcoidosis (CS) can mimic any cardiomyopathy due to its ability to manifest with a variety of clinical presentations. The exact prevalence of CS remains unknown but has been reported ranging from 2.3% to as high as 29.9% among patients presenting with new onset cardiomyopathy and/or atrioventricular block. Early and accurate diagnosis of CS is often challenging due to the nature of disease progression and lack of diagnostic reference standard. The current diagnostic criteria for CS are lacking in sensitivity and specificity. Here, we review the contemporary role of advanced imaging modalities such as cardiac magnetic resonance imaging and positron emission tomography/computed tomography imaging in diagnosing and prognosticating patients with CS.

Update on cardiac sarcoidosis

Cardiac sarcoidosis is an inflammatory myocardial disease of unknown etiology. It is characterized by the deposition of non-caseating granulomas that may involve any part of the heart. Cardiac sarcoidosis is often under-diagnosed or recognized partly due to the heterogeneous clinical presentation of the disease. The three most frequent clinical manifestations of cardiac sarcoidosis are atrioventricular block, ventricular arrhythmias, and heart failure. A definitive diagnosis of cardiac sarcoidosis can be made with histology findings from an endomyocardial biopsy. However, the diagnosis in the majority of cases is based on findings from the clinical presentation and advanced imaging due to the low sensitivity of endomyocardial biopsy. The Heart Rhythm Society (HRS) 2014 expert consensus statement and the Japanese Ministry of Health and Welfare criteria are the two most commonly used diagnostic criteria sets. This review article summarizes the available evidence on cardiac sarcoidosis, focusing on the diagnostic criteria and stepwise approach to its management.

Sarcoid Heart Disease: Review of Current Knowledge

Sarcoidosis is a granulomatous disease with the potential of multiple organ system involvement and its etiology remains unknown. Cardiac involvement is associated with worse clinical outcome, and has been reported to be 20-30% in white and as high as 58% in Japanese populations with sarcoidosis. Clinical manifestations of cardiac sarcoidosis highly depend on the extent and location of granulomatous inflammation. The most frequent presentations include heart block, tachyarrhythmia, or heart failure. Endomyocardial biopsy is the most specific diagnostic test, but has poor sensitivity due to often patchy involvement. The diagnosis of cardiac sarcoidosis remains challenging due to nonspecific imaging findings. Both 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) and cardiac magnetic resonance imaging can be used to evaluate cardiac sarcoidosis, but evaluate different stages of the disease process. FDG-PET detects metabolically active inflammatory cells while cardiac magnetic resonance imaging with late gadolinium enhancement reveals areas of myocardial necrosis and fibrosis. Aggressive therapy of symptomatic cardiac sarcoidosis is often sought due to the high risk of sudden death and/or progression to heart failure. Prednisone 20-40 mg a day is the recommended initial treatment. In refractory or severe cases, higher doses of prednisone, 1-1.5 mg/kg/d (or its equivalent) and addition of a steroid-sparing agent have been utilized. Methotrexate is added most commonly. Long-term improvement has been reported with the use of a combination of weekly methotrexate and prednisone versus prednisone alone. After initiation of treatment, a cardiac FDG-PET scan may be performed 2-3 months later to assess treatment response.

Unexpected Case of Cardiac Sarcoidosis in a Caucasian Male

Cardiac sarcoidosis (CS) is an underappreciated diagnosis in healthy patients presenting with recurrent syncope. This may be particularly limited in patients who do not meet common epidemiology and manifestations of sarcoidosis, which are typically African American women and pulmonary, respectively. In our case, we have a previously healthy middle-aged Caucasian American male who presented with recurrent syncope for one week. Initial electrocardiogram showed a right bundle branch block with a normal P-R interval. A few days into the admission, the patient suffered another episode of syncope precipitated by micturition, and repeat electrocardiogram revealed evolution to complete atrioventricular block, necessitating emergent placement of a temporary permanent pacemaker. Transthoracic echocardiogram showed preserved left ventricular ejection fraction of 55%-60% with normal heart valves. Chest computerized tomography revealed few pulmonary nodules, prompting a weak concern for infiltrative disease, e.g., sarcoidosis. To evaluate for possible cardiac structural abnormalities, a cardiac magnetic resonance imaging (MRI) study was considered but precluded by the presence of MRI-incompatible temporary pacemaker. Despite low suspicion, a fluorodeoxyglucose-positron emission tomography was obtained which unexpectedly revealed hypermetabolic lymph nodes in the perihilar, supraclavicular, and mediastinal regions as well as an area along the interventricular septum, consistent with atrioventricular (AV) conduction pathways. As the patient met major criteria for CS per Japanese Circulation Society guidelines, a tentative diagnosis was made, and a Biotronik single-chamber implantable cardiac defibrillator was ultimately placed. On outpatient follow-up, endobronchial ultrasound-guided fine-needle biopsy of perihilar lymph nodes revealed only rare epithelioid histiocytes, rare alveolar macrophages, and benign bronchial cells, consistent with benign nodal tissue. Further attempts for histological confirmation were aborted due to profound calcification and location of affected lymph nodes. A decision was made to defer further biopsy, including the gold standard of diagnosis endomyocardial biopsy, due to the risks outweighing the benefits. He initiated medical therapy with prednisone and mycophenolate, as well as trimethoprim-sulfamethoxazole for Pneumocystis prophylaxis. Unlike general sarcoidosis, which is often considered a benign systemic disease, CS has high potential for severe complications including arrhythmia, systolic heart failure, and sudden cardiac death. In general, males carry a higher risk of CS than females, especially those who are of African American descent as they carry a higher incidence of nonspecific sarcoidosis. Expectations related to our patient's demographic initially delayed diagnostic workup for infiltrative disease, primarily focusing on intracranial, orthostatic, and infectious causes. This case report serves to inform clinicians on early manifestations of CS, raise awareness of its incidence in unexpected demographics, and encourage them to consider infiltrative diseases when presented with patients of similar symptoms.

Real-time three-dimensional echocardiography for detection of cardiac sarcoidosis in the early stage: a cross-sectional single-centre study

BACKGROUND

Sarcoidosis with cardiac involvement has a relatively high morbidity and mortality, and early diagnose of cardiac sarcoidosis is a critical issue. Systolic dyssynchrony index (SDI) measured by three-dimensional echocardiography was used in our study for detection of subclinical left ventricular (LV) systolic dysfunction in patients with sarcoidosis and normal LV function on two-dimensional echocardiography.

METHODS

Forty-four patients diagnosed with sarcoidosis (without clinically apparent cardiac involvement) and 44 healthy control subjects were included in this study. Two-dimensional echocardiographic parameters, also LV volumes and SDI measured by 3D echocardiography were analyzed in all participants.

RESULTS

While two-dimensional echocardiographic results of both study groups were similar; SDI_16 (SDI for 16 segments of LV) results were significantly higher in sarcoidosis group compared to healthy controls (6.99 ±5.02 vs 2.89 ± 1.32, p < 0.0001).

CONCLUSION

SDI_16 was higher in patients with sarcoidosis compared to healthy controls probably due to patchy infiltration characteristic of the disease. This parameter could be used as a marker to identify patients with cardiac involvement of sarcoidosis in the early phase.

Machine learning predicting mortality in sarcoidosis patients admitted for acute heart failure

Background

Sarcoidosis with cardiac involvement, although rare, has a worse prognosis than sarcoidosis involving other organ systems.

Objective

We used a large dataset to train machine learning models to predict in-hospital mortality among sarcoidosis patients admitted with heart failure (HF).

Method

Utilizing the National Inpatient Sample, we identified 4659 patients hospitalized with a primary diagnosis of HF. In this cohort, we identified patients with a secondary diagnosis of sarcoidosis using International Statistical Classification of Disease, Tenth Revision (ICD-10) codes. Patients were separated into a training group and a testing group in a 7:3 ratio. Least absolute shrinkage and selection operator regression was used to select variables to prevent model overfitting or underfitting. For machine learning models, logistic regression, random forest, and XGBoosting were applied in the training group. Parameters in each of the models were tuned using the GridSearchCV function. After training, all models were further validated in the testing group. Models were then evaluated using the area under curve (AUC) score, sensitivity, and specificity.

Results

A total of 2.3% of sarcoidosis patients died in HF admission. Our machine learning model analysis found the RF model to have the highest AUC score and sensitivity. Feature analysis found that comorbid arrhythmias and fluid electrolyte disorders were the strongest factors in predicting in-hospital mortality.

Conclusion

Machine learning methods can be useful in identifying predictors of in-hospital mortality in a given dataset.

Phenotypic and HLA-DRB1 allele characterization of Swedish cardiac sarcoidosis patients

BACKGROUND

Early detection and initiation of treatment in cardiac sarcoidosis (CS) is believed to be crucial to reduce morbidity and mortality. The diagnosis of CS is challenging, especially in isolated CS (ICS). Certain human leukocyte antigen (HLA-DRB1) alleles associate with different phenotypes of sarcoidosis. Phenotypic and genotypic characterization of patients with CS may improve our ability to identify patients being at risk for developing CS.

METHODS

87 patients with CS, identified at two Swedish university hospitals were included. Phenotypic characteristics were extracted from the medical records and the patients were HLA-DRB1 typed.

RESULTS

Median age at diagnosis was 55 years, 37% were women. HLA-DRB1 distribution was similar to a general sarcoidosis population. A majority of patients (51/87) had CS as the first sarcoidosis presentation. They were younger (p = 0.04), more often presenting with ventricular tachycardia (VT) or atrioventricular block (AVB) grade II or III (p < 0.001), had lower left ventricular ejection fraction (LVEF) (p = 0.002), lower serum angiotensin converting enzyme (s-ACE) (p = 0.025), and fewer extra cardiac manifestations (ECM) (p = 0.02) than those presenting with CS later.

CONCLUSIONS

Of Swedish CS patients, 59% presented with cardiac involvement as first manifestation. They had more severe cardiac symptoms than patients presenting with CS later. This phenotype disclosed less ECM and lower s-ACE thus diagnosis can be missed or delayed. We did not observe significant differences in HLA-DRB1 allele frequency between patients with CS compared to sarcoidosis in general. Awareness of CS as a primary manifestation can enable early detection and adequate intervention.

Patient profile and comparison of three diagnostic criteria for cardiac sarcoidosis in a tuberculosis endemic population

BACKGROUND

Cardiac sarcoidosis (CS) is an underdiagnosed and life-threatening condition. Histopathological diagnosis is difficult due to the risks and variable diagnostic yield of endomyocardial biopsy.

OBJECTIVES

To study the clinical profile and compare the diagnostic criteria of CS in a cohort of sarcoidosis.

METHODS

A retrospective review of the Sarcoidosis database (375 patients) was performed to identify patients with CS. Demographic and clinical details were retrieved. We applied the available diagnostic criteria for the diagnosis of CS: The World Association of Sarcoidosis and Other Granulomatous Diseases (WASOG), Heart Rhythm Society (HRS), and Japanese Ministry of Health and Welfare (JMHW) criteria.

RESULTS

Out of the 375 patients, 15 (4%) were identified with CS. The median age was 41 years, and 53% were female. The most common symptoms were breathlessness, palpitation, and fatigue in 80%, 53.3%, and 46.6% of patients, respectively. Tuberculin positivity (≥ 10mm induration) was seen in 26.6%. 80% and 53.3% of the patients had abnormal ECG and 2D echocardiography findings, respectively. Six patients had a history of Ventricular tachycardia (40%). LV Ejection fraction was reduced in 12 subjects (80%). Cardiac-MRI showed late gadolinium enhancement in 53.3%. A definitive histopathological diagnosis for sarcoidosis was established in 86.6% (13/15) patients. Of the 15, all satisfied JMHW criteria and WASOG criteria (12 (80%) at least probable category, 3 (20%) possible CS), and 13 (86.6%) met HRS criteria for a diagnosis of CS.

CONCLUSION

In a cohort of 375 patients with sarcoidosis in a tuberculosis endemic setting, 4% were diagnosed with cardiac sarcoidosis. Histopathological diagnosis may be obtained by sampling from extracardiac sites. JMHW and WASOG criteria perform equally well in TB endemic settings.

Myocarditis in systemic immune-mediated diseases: Prevalence, characteristics and prognosis. A systematic review

Many systemic immune-mediated diseases (SIDs) may involve the heart and present as myocarditis with different histopathological pictures, i.e. lymphocytic, eosinophilic, granulomatous, and clinical features, ranging from a completely asymptomatic patient to life-threatening cardiogenic shock or arrhythmias. Myocarditis can be part of some SIDs, such as sarcoidosis, systemic lupus erythematosus, systemic sclerosis, antiphospholipid syndrome, dermato-polymyositis, eosinophilic granulomatosis with polyangiitis and other vasculitis syndromes, but also of some organ-based immune-mediated diseases with systemic expression, such as chronic inflammatory bowel diseases. The aim of this review is to describe the prevalence, main clinical characteristics and prognosis of myocarditis associated with SIDs.

Cardiac sarcoidosis: from diagnosis to treatment

Sarcoidosis is a systemic granulomatous disease of unknown cause. Its clinical presentations are heterogeneous and virtually any organ system can be affected, most commonly lungs. The manifestations of cardiac sarcoidosis (CS) are heterogenous depending on the extent and location of the disease and range from asymptomatic forms to life-threatening arrhythmias as well as to progressive heart failure. Cardiac involvement is associated with a worse prognosis. The diagnosis of CS is often challenging and requires a multimodality approach based on current international recommendations. Pharmacological treatment of CS is based on administration of anti-inflammatory therapy (mainly corticosteroids), which is often combined with heart failure medication and/or antiarrhythmics. Nonpharmacological therapeutic approaches in CS cover pacemaker or defibrillator implantation, catheter ablations and heart transplantation. This review aims to summarize the current understanding of CS including its epidemiology, etiopathogenesis, clinical presentations, diagnostic approaches, and therapeutic possibilities.

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.

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.

Azithromycin for sarcoidosis cough: an open-label exploratory clinical trial

Background

Chronic cough is a distressing symptom for many people with pulmonary sarcoidosis. Continuous treatment with a macrolide antibiotic may improve cough. We aimed to assess the potential efficacy of azithromycin in patients with sarcoidosis and self-reported cough.

Methods

We conducted a noncontrolled, open-label clinical trial of azithromycin 250 mg once daily for 3 months in patients with pulmonary sarcoidosis who reported a chronic cough. The primary outcome was number of coughs in 24 h. Secondary outcomes were cough visual analogue scales and quality of life measured using the Leicester Cough Questionnaire and King's Sarcoidosis Questionnaire. Safety outcomes included QTc interval on ECG. Measurements were made at baseline and after 1 and 3 months of treatment.

Results

All 21 patients were white, median age 57 years, 9 males, 12 females, median 3 years since diagnosis. Five were taking oral corticosteroids and none were taking other immunosuppressants. Twenty patients completed the trial. The median (range) number of coughs in 24 h was 228 (43–1950) at baseline, 122 (20–704) at 1 month, and 81 (16–414) at 3 months (p=0.002, Friedman's test). The median reduction in cough count at 3 months was 49.6%. There were improvements in all patient-reported outcomes. Azithromycin was well tolerated.

Conclusion

In a noncontrolled open-label trial in people with sarcoidosis who reported a chronic cough, 3 months of treatment with azithromycin led to improvements in a range of cough metrics. Azithromycin should be tested as a treatment for sarcoidosis cough in a randomised placebo-controlled trial.

In a noncontrolled open-label trial in people with sarcoidosis who reported a chronic cough, 3 months of treatment with azithromycin led to improvements in a range of cough metricshttps://bit.ly/2FB5tfq

CASPA (CArdiac Sarcoidosis in PApworth) improving the diagnosis of cardiac involvement in patients with pulmonary sarcoidosis: protocol for a prospective observational cohort study

INTRODUCTION

Sarcoidosis is a multisystem disease, predominantly affecting the lungs but can involve the heart, resulting in cardiac sarcoidosis (CS). Patients require MRI/Positron Emission Tomography (PET) scans for diagnosis. Echocardiography, ECG and Holter monitoring may be indicative but not diagnostic alone. Patients can present late with conduction defects, heart failure or sudden death. The CASPA (CArdiac Sarcoidosis in PApworth) study protocol aims to (1) use MRI to identify CS prevalence; (2) use speckle-tracking echocardiography, signal averaged ECG and Holter monitoring to look for diagnostic pathways; and (3) identify serum proteins which may be associated with CS.

METHODS AND ANALYSIS

Participants with pulmonary sarcoidosis (and no known cardiac disease) from Royal Papworth Hospital will have the following: cardiac MRI with late gadolinium, two-dimensional transthoracic echocardiography with speckle tracking, signal averaged ECG and 24-hour Holter monitor. They will provide a serum sample for brain natriuretic peptide levels and proteomics by liquid chromatography coupled to high-resolution mass spectrometry. All data will be collected on OpenClinica platform and analysed approximately 6 months after final patient recruitment.

ETHICS AND DISSEMINATION

The Camden & Kings Cross Research Ethics Committee approved the protocol (REC number: 17/LO/0667). Integrated Research Approval System (IRAS) 222 720. Dissemination of findings will be via conference presentations and submitted to peer-reviewed journals.

Update in Cardiac Sarcoidosis

Increasing awareness of cardiac manifestations of sarcoidosis and the widespread availability of advanced imaging tests have led to a tidal wave of interest in a condition that was once considered rare. In this Focused Review, we explore important clinical questions that may confront specialists faced with possible cardiac involvement. In the absence of an ideal reference standard, three main sets of clinical criteria exist: the Japanese Ministry of Health and Welfare, the Heart Rhythm Society, and the World Association for Sarcoidosis and Other Granulomatous Disorders criteria. Once cardiac sarcoidosis is suspected, clinicians should be familiar with the prevalence of the disease in different clinical scenarios. Before obtaining advanced cardiac imaging, electrocardiogram, ambulatory electrocardiogram, echocardiogram, and B-type natriuretic peptide may be useful. The available therapies for cardiac sarcoidosis include immunosuppression, antiarrhythmic medications, heart failure medications, device therapy, ablation therapy, and heart transplantation. Contemporary data suggest that long-term survival in cardiac sarcoidosis is better than previously believed. There is no randomized controlled trial demonstrating benefits of screening, but screening is recommended based on observational data.

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.

Cardiac sarcoidosis: worse pulmonary function due to left ventricular ejection fraction?: A case-control study

Dyspnea and exercise intolerance are usually attributed to pulmonary disease in sarcoidosis patients. However, cardiac involvement may also be responsible for these symptoms. Data regarding the impact of heart involvement on lung function in cardiac sarcoidosis (CS) is limited.The aim of study was to compare the results of pulmonary function tests (PFTs) in patients with and without heart involvement. We performed a retrospective analysis of PFTs in a group of sarcoidosis patients both with and without heart involvement evaluated by cardiovascular magnetic resonance (CMR) study. The study was performed in the period between May 2008 and April 2016.We included data of sarcoidosis patients who underwent testing for possible CS (including CMR study) at a national tertiary referral center for patients with interstitial lung diseases. All patients had histopathologicaly confirmed sarcoidosis and underwent standard evaluation with PFTs measurements including spirometry, plethysmography, lung transfer factor (TL,CO), and 6-minute walking test (6MWT) assessed using the most recent predicted values.We identified 255 sarcoidosis patients (93 women, age 42 ± 10.7 y): 103 with CS and 152 without CS (controls). CS patients had significantly lower left ventricular ejection fraction (LVEF; 56.9 ± 7.0 vs 60.4 ± 5.4, P < .001). Any type of lung dysfunction was seen in 63% of CS patients compared with 31% in the controls (P = .005). Ventilatory disturbances (obstructive or restrictive pattern) and low TL,CO were more frequent in CS group (52% vs 23%, P < .001 and 38% vs 18% P < .01 respectively). CS (OR = 2.13, 95% CI: 1.11-4.07, P = .02), stage of the disease (OR = 3.13, 95% CI: 1.4-7.0, P = .006) and LVEF (coefficient = -0.068 ± 0.027, P = .011) were independent factors associated with low FEV1 but not low TL,CO. There was a significant correlation between LVEF and FEV1 in CS group (r = 0.31, n = 89, P = .003). No significant difference in 6MWD between CS patients and controls was observed.Lung function impairment was more frequent in CS. Lower LVEF was associated with decreased values of FEV1. Relatively poor lung function may be an indication of cardiac sarcoidosis.

Diagnostic approach for cardiac involvement in sarcoidosis

AIMS

Cardiac sarcoidosis (CS) is a potentially life-threatening condition. Early detection of CS is therefore important. The aim of this study was to eludicate the usefulness of different investigations in a subgroup of patients with sarcoidosis regarded as having an increased risk for cardiac involvement.

METHODS

42 sarcoidosis patients, who had an abnormal resting electrocardiogram (ECG) and/or symptoms indicating possible cardiac involvement (i.e. palpitations, pre-syncope or syncope), were included in the study. They were identified in a consecutive manner among patients followed-up at outpatient clinics for respiratory disorders. Holter monitoring, exercise test, transthoracic echocardiogram (TTE), cardiovascular magnetic resonance (CMR) and analysis of N-terminal pro B-type natriuretic peptide (NT-pro-BNP) in serum were performed. Note, that the role of FDG-PET was not investigated in this study.

RESULTS

In the group with a pathologic ECG 11/25 (44%) were ultimately diagnosed with CS (all with pathologic CMR). However, in the group with only symptoms but a normal ECG just 1/17 got the diagnosis CS (p<0.05). This patient had a pathologic Holter monitoring. The risk for CS was increased if serum NT-pro-BNP was elevated (i.e. NT-pro-BNP>125 ng/L), sensitivity 78% (p<0.05), specificity 67%. By adding a pathologic ECG to an elevated NT-pro-BNP increased specificity to 93% and sensitivity remained at 78%.

CONCLUSION

Our findings indicate that CMR should be performed at an early stage in sarcoidosis patients with an abnormal resting ECG. Holter monitoring and elevated levels of NT-pro-BNP may enhance the diagnostic accuracy whereas exercise testing and TTE in this study had less impact on the identification of CS.

Cardiac sarcoidosis - an expert review for the chest physician

Introduction: Sarcoidosis is a multisystem granulomatous disease predominantly affecting the lungs, with increased risk of cardiovascular disease, pulmonary hypertension and cardiac sarcoidosis (CS), the latter due to direct granuloma infiltration. Sarcoidosis is often managed by chest physicians who need to understand the diagnostic pathways and initial management plans for patients with cardiac involvement. Areas covered: The most serious consequence of CS is sudden cardiac death due to ventricular tachyarrhythmias or complete atrioventricular block. Additional complications include atrial arrhythmias and congestive cardiac failure. There are no internationally accepted screening pathways, but a combination of history, clinical examination and ECG detects up to 85% of cases. Newer modalities including signal-averaged ECG and speckle-tracking echocardiography increase identification of patients who require a definitive diagnosis. Early immunosuppression reduces the risk of conduction abnormalities and incidence of supraventricular arrhythmias. Management of ventricular arrhythmias requires antiarrhythmic medications followed by possible catheter ablation and device (ICD) implantation. Expert commentary: Prospective trials are underway to identify the optimum methods for screening, which will guide future international statements on indications for and methods of screening in CS.

The burden of cardiac arrhythmias in sarcoidosis: a population-based inpatient analysis

Background

Cardiac involvement in the sarcoidosis is known to ensue with diverse clinical forms and its investigation is challenging at times. This article features the under-perceived burden, patterns, and outcomes of different arrhythmias, which may have a prognostic significance in patients with sarcoidosis.

Methods

We queried the National Inpatient Sample (NIS) for 2010-2014 to recognize sarcoidosis, arrhythmia, and comorbidities affecting hospitalizations. The nationwide estimates were attained using discharge records. We assessed incidence and trends in sarcoidosis-related arrhythmia and consequential inpatient mortality, hospital length of stay (LOS), hospitalization charges and predictors of mortality with multivariate analysis.

Results

We identified 369,285 sarcoidosis-related hospitalizations. Of these, nearly one-fifth suffered from arrhythmias (n=73,424). The sarcoidosis patients developing arrhythmias were older (61.9 vs. 56.0 years) compared to those without. Males had the higher incidence of arrhythmias compared to females. Atrial fibrillation (Afib) (10.97%) was the most common subtype, followed by ventricular tachycardia (1.97%). There was a rising trend in arrhythmia-related hospital admissions and mortality among sarcoidosis, with Afib incidence displaying the highest increase. Traditional cardiac comorbidities were higher in the sarcoid-arrhythmia group. The arrhythmia group had significantly higher mortality (3.7% vs. 1.5%), mean hospital LOS (6.4 vs. 5.2 days) and hospital charges ($64,118 vs. $41,565) compared to non-arrhythmia group (P<0.001). Incident arrhythmia significantly increased the mortality odds in sarcoidosis (adjusted odds ratio, 2.06).

Conclusions

The growing trend, deteriorating outcomes and higher mortality associated with sarcoid-related arrhythmias highlight the importance of timely diagnosis and aggressive management in this population.

A case report of steroid resistant cardiac sarcoidosis successfully managed with methotrexate

Up to one fourth of sarcoidosis patients may have cardiac involvement, what is potentially a life-threatening condition and requires aggressive treatment. Corticosteroids are generally effective in cardiac sarcoidosis, however may have significant short and long term adverse effects. We present a case of a 42-year-old male, who was diagnosed with pulmonary and cardiac sarcoidosis. He was treated initially with corticosteroids and satisfactory improvement was achieved in the lungs but not in the heart. Methotrexate was added as a second line therapy, being beneficial for the heart as well as steroid sparing agent. Cardiac improvement was documented during serial CMR imaging. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 178-181).

Cardiac Sarcoidosis: A Review of Contemporary Challenges in Diagnosis and Treatment

Sarcoidosis is a systemic disease characterized by noncaseating granulomas and is often a diagnosis of exclusion. The actual prevalence of cardiac sarcoidosis (CS) is unknown, as studies have demonstrated mixed data. CS may be asymptomatic and is likely more frequently encountered than previously thought. Sudden death may often be the presenting feature of CS. Most deaths attributed to CS are caused by arrhythmias or conduction system disease, and congestive heart failure may occur. Current expert consensus on diagnosis of CS continues to rely on endomyocardial biopsy, in the absence of which, histologic proof of extracardiac sarcoid involvement is necessitated. Emergence of newer noninvasive imaging modalities such as cardiac magnetic resonance imaging and positron emission tomography, have become increasingly popular tools utilized in patients with both clinical and asymptomatic CS, and have demonstrated good diagnostic capability. The main therapeutic approaches in patients with CS can be broadly divided into the following 2 categories: pharmacological management and invasive or device oriented. However, much remains unknown about the optimal screening protocols of asymptomatic patients with extracardiac sarcoidosis and treatment of biopsy-proven CS. Our knowledge about CS has amplified significantly over the last 30 years and the growing realization that this process is often asymptomatic is paving the way for better screening protocols and earlier detection of this serious condition.