Cardiac sarcoidosis: diagnosis and management.

OPINION STATEMENT: Cardiac sarcoidosis can be life threatening if not promptly diagnosed and treated appropriately and aggressively. The diagnosis of myocardial disease is often difficult and circumstantial because there are no reliable diagnostic tests. Except for the finding of noncaseating granulomas on endomyocardial biopsy, most tests are limited and nonspecific. Therefore, the decision of initiating treatment is based on the patient's symptoms and the course of the disease, rather than on the presence of histologic confirmation. The goal of therapy is to prevent irreversible cardiomyopathy and to thwart the progression to heart transplantation. The mainstay of treatment is corticosteroids, although there are no large randomized trials analyzing corticosteroid use. The combination with other immunosuppressant agents, such as Methotrexate and Azathioprine, is initiated on the patient's failing or experiencing severe side effects from corticosteroids. While there are small studies proving the efficacy of tumor necrosis factor-inhibitors in cardiac sarcoidosis, more experience with these agents is needed. Catheter ablation or placement of implantable devices is indicated prophylactically in patients with severe ventricular tachyarrhythmias. Heart transplantation should be considered in patients with severe heart failure refractory to medical therapy. This article focuses on the current diagnostic tests and treatment recommendations for cardiac sarcoidosis.