Sex differences in cardiac sarcoidosis

A recent publication by Duvall and colleagues, from an urban US academic centre, reported a mean age at diagnosis of 53 years, which is in keeping with findings from this study but, in contrast, more common in men than women.5 Interestingly, only ~5% of the patients received a steroid-sparing agent, which is likely a reflection of the timeline over which data were collected. In the current era, some centres use steroid-sparing agents early in the treatment course in an effort to ameliorate the adverse effects of chronic corticosteroids, though this is not universal.6 Data regarding their use are mostly extrapolated from pulmonary sarcoidosis, with some smaller studies describing the use of mycophenolate mofetil and methotrexate in CS, though large studies are lacking, as are guidelines for medical therapy. FDG-PET has a reasonable sensitivity and specificity for detecting inflammation,7 and it is commonly accepted that active inflammation can be a driving force for ventricular arrhythmias, particularly in the setting of VT storm/incessant VT.8 Myocardial scar burden, as exhibited by LGE, is also known to play a role in ventricular arrhythmias in CS, the difficulty being, particularly when a patient presents in extremis, which is the driving force at any given time. Chang and colleagues showed that of 27 patients with focal ventricular arrhythmias on electrophysiology study, only one was qualitatively from a similar region as FDG uptake on PET imaging, indicating lack of correlation between anatomical active inflammation and focal ventricular arrhythmias.9 This is relevant when determining the appropriate treatment strategy, immunosuppression or antiarrhythmic therapy/catheter ablation.