CMR imaging predicts death and other adverse events in suspected cardiac sarcoidosis

Greulich, Simon; Deluigi, Claudia Christina; Gloekler, Steffen; Wahl, Andreas; Zürn, Christine; Kramer, Ulrich; Nothnagel, Detlev; Bültel, Helmut; Schumm, Julia; Grün, Stefan; Ong, Peter; Wagner, Anja; Schneider, Steffen; Nassenstein, Kai; Gawaz, Meinrad; Sechtem, Udo; Bruder, Oliver; Mahrholdt, Heiko (2013). CMR imaging predicts death and other adverse events in suspected cardiac sarcoidosis. JACC. Cardiovascular imaging, 6(4), pp. 501-511. Elsevier 10.1016/j.jcmg.2012.10.021

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OBJECTIVES

This study aimed to demonstrate that the presence of late gadolinium enhancement (LGE) is a predictor of death and other adverse events in patients with suspected cardiac sarcoidosis.

BACKGROUND

Cardiac sarcoidosis is the most important cause of patient mortality in systemic sarcoidosis, yielding a 5-year mortality rate between 25% and 66% despite immunosuppressive treatment. Other groups have shown that LGE may hold promise in predicting future adverse events in this patient group.

METHODS

We included 155 consecutive patients with systemic sarcoidosis who underwent cardiac magnetic resonance (CMR) for workup of suspected cardiac sarcoid involvement. The median follow-up time was 2.6 years. Primary endpoints were death, aborted sudden cardiac death, and appropriate implantable cardioverter-defibrillator (ICD) discharge. Secondary endpoints were ventricular tachycardia (VT) and nonsustained VT.

RESULTS

LGE was present in 39 patients (25.5%). The presence of LGE yields a Cox hazard ratio (HR) of 31.6 for death, aborted sudden cardiac death, or appropriate ICD discharge, and of 33.9 for any event. This is superior to functional or clinical parameters such as left ventricular (LV) ejection fraction (EF), LV end-diastolic volume, or presentation as heart failure, yielding HRs between 0.99 (per % increase LVEF) and 1.004 (presentation as heart failure), and between 0.94 and 1.2 for potentially lethal or other adverse events, respectively. Except for 1 patient dying from pulmonary infection, no patient without LGE died or experienced any event during follow-up, even if the LV was enlarged and the LVEF severely impaired.

CONCLUSIONS

Among our population of sarcoid patients with nonspecific symptoms, the presence of myocardial scar indicated by LGE was the best independent predictor of potentially lethal events, as well as other adverse events, yielding a Cox HR of 31.6 and of 33.9, respectively. These data support the necessity for future large, longitudinal follow-up studies to definitely establish LGE as an independent predictor of cardiac death in sarcoidosis, as well as to evaluate the incremental prognostic value of additional parameters.

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