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Review

Utilization of cardiac imaging in sarcoidosis

, &
Pages 253-266 | Received 01 Dec 2021, Accepted 20 Apr 2022, Published online: 01 May 2022
 

ABSTRACT

Introduction

Cardiac sarcoidosis (CS) is the cardiac, and occasionally the only manifestation, of a systemic disease of unknown etiology inherently challenging to definitively diagnose due to the lack of a reliable gold standard, the current being endomyocardial biopsy, the yield of which is low owing to the patchy nature of involvement. Societal guidelines employ specific criteria to make a probabilistic diagnosis, integrating clinical assessment with conventional and advanced cardiac imaging.

Areas covered

This review begins with an introduction to CS, followed by a discussion of diagnostic guidelines commonly used, then delves into an in-depth review of the imaging modalities currently available to assess for CS. Particular attention is made to discussing findings, strengths, limitations, and future directions for each modality.

Expert opinion

The burden of CS may be significantly larger than previously thought. With the low yield of endomyocardial biopsy, advanced cardiac imaging is increasingly employed to determine CS likelihood. Cardiac magnetic resonance is adept at detecting myocardial scar and able to differentiate between CS and other cardiomyopathies. F-18 Fluorodeoxyglucose positron emission tomography is superior at detecting active disease (myocardial inflammation) which may be amenable to immunosuppressive treatment, as well as detecting extracardiac involvement and identifying potential biopsy sites.

Article highlights

  • The incidence of cardiac sarcoidosis (CS) is on the rise, either due to improved detection, truly increased disease incidence, or both.

  • Definitive diagnosis requires tissue evidence, but the patchy nature of myocardial involvement renders the yield of an endomyocardial biopsy low.

  • The two main societal guidelines: the Heart Rhythm Society and the Japanese Circulation Society utilize criteria to make a probabilistic diagnosis.

  • Patients with systemic sarcoidosis should be screened by clinical history/examination and electrocardiography.

  • Advanced cardiac imaging with cardiac magnetic resonance (CMR) and/or F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) is valuable for CS detection in patients with extracardiac sarcoidosis with test findings or clinical picture suggestive of isolated CS.

  • CMR is useful for detecting myocardial scar and for differentiation between CS and other cardiomyopathies, while FDG PET is useful for detecting and following up disease activity and extracardiac involvement.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers in this manuscript have no relevant financial or other relationships to disclose.

List of abbreviations

ASNC=

American Society of Nuclear Cardiology

AV=

Atrioventricular

BBB=

Bundle branch block

CAD=

Coronary artery disease

CMR=

Cardiac Magnetic Resonance

CS=

Cardiac Sarcoidosis

CT=

Computed Tomography

DNA=

Deoxyribonucleic Acid

ECG=

Electrocardiogram

EMB=

Endomyocardial Biopsy

FDG=

Fluorodeoxyglucose

FLT=

Fluorothymidine

FWHM=

Full width at half maximum

GLS=

Global Longitudinal Strain

HFLC=

High-Fat-Low-Carbohydrate

HRS=

Heart Rhythm Society

JCS=

Japanese Circulation Society

JMHW=

Japanese Ministry of Health And Welfare

LGE=

Late Gadolinium Enhancement

LV=

Left Ventricle

LVEF=

Left Ventricular Ejection Fraction

MBF=

Myocardial Blood Flow

MFR=

Myocardial flow reserve

MPI=

Myocardial perfusion imaging

MR=

Magnetic resonance

MRI=

Magnetic Resonance Imaging

PET=

Positron Emission Tomography

PVC=

Premature Ventricular Contraction

ROI=

Region of interest

RV=

Right ventricle

RWMA=

Regional wall motion abnormalities

SCD=

Sudden cardiac death

SNMMI=

Society of Nuclear Medicine and Molecular Imaging

SPECT=

Single photon emission computed tomography

SUV=

Standardized uptake value

tCMA=

Total cardiac metabolic activity

VF=

Ventricular fibrillation

VT=

Ventricular tachycardia

Additional information

Funding

This paper was not funded.

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