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(Chest. 2006;129:1113.)
© 2006 American College of Chest Physicians

Cardiac Sarcoidosis

Alvin S. Teirstein, MD, FCCP; Michael Iannuzzi, MD, FCCP and Maria L. Padilla, MD, FCCP

Mount Sinai Medical Center, New York, NY

Correspondence to: Alvin S. Teirstein, MD, FCCP, Mount Sinai School of Medicine, Mount Sinai Medical Center, 1 Gustave Levy Pl, PO Box 1232, New York, NY 10029-6574; e-mail: alvin.teirstein{at}msnyuhealth.org

To the Editor:

In their report on cardiac sarcoidosis, Smedema et al (July 2005)1 remarkably conclude that patients without cardiac symptoms do not require more sensitive studies to detect heart disease. This report, while of interest, is limited by a patient follow-up that varied widely from 3 to 54 months. Since this study does not well characterize the natural history of asymptomatic cardiac sarcoidosis and, as related in the accompanying editorial by Judson,2 sudden death is a tragic occurrence in seemingly healthy young patients, the conclusions of Smedema et al1 are not reassuring. The authors list "heart failure" as the symptom of cardiac involvement in 14 of their 19 patients, and only 7 patients are listed as having "probable arrhythmias." Thus, it appears that the cause of morbidity and mortality from cardiac sarcoidosis has shifted from death due to fatal malignant arrhythmias to death due to progressive loss of left ventricular function. Presumably, the loss of ventricular function and arrhythmias are due to granulomatous inflammation or myocardial scarring. We think that the early recognition of active myocardial sarcoidosis such as with MRI, as found in 12 of the 82 patients who were deemed not to have cardiac sarcoidosis, or utilizing other sensitive tests such as positron emission tomography scans might have alerted the physicians to the presence of treatable myocardial disease.

The awareness of myocardial involvement allows anticipatory monitoring. Such monitoring permits intervention prior to the evolution of clinical symptoms. Smedema et al1 have reaffirmed the conclusions of prior studies that have emphasized the poor prognosis of patients with clinically apparent cardiac sarcoidosis. They also have reaffirmed the fact that the severity of lung disease offers ambiguous clues with more advanced radiographic stage occurring in their clinical cardiac group, but worse pulmonary function in the noncardiac group. They have not addressed the more pressing problem of how to prevent this tragic complication. There is little comfort in knowing that your patient has not yet developed life-threatening cardiac symptoms.

References

  1. Smedema, JP, Snoep, G, van Kroonenburgh, MP, et al (2005) Cardiac involvement in patients with pulmonary sarcoidosis assessed at two university medical centers in the Netherlands. Chest 128,30-35[Abstract/Free Full Text]
  2. Judson, MA Cardiac sarcoidosis: there is no instant replay [editorial]. Chest 2005;128,3-6[Free Full Text]




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