Heart failure and sarcoidosis - July 19, 2012

Thank you to team 7 for bringing a fascinating case, and to Dr. Rakowski for hosting.

Today, we discussed a case of a patient with sarcoidosis who presented with heart failure.  Regardless of whether we think that is the true cause of our patient’s symptoms, cardiac manifestations of sarcoidosis is interesting.

I have included 2 references here:

- a review article from New England Journal of Medicine about sarcoidosis in general (IannuzziMC, Rybicki BA, Teirstein AS. Sarcoidosis.  N Engl J Med. 2007Nov 22;357(21):2153-65.).

- a review article about cardiac sarcoidosis specifically (Kim JS et al.  Cardiac sarcoidosis.  Am Heart J. 2009 Jan;157(1):9-21. Epub 2008Nov 12.).

Information from this blog taken from the above 2 references, and of course, what we talked about in morning report today.

Sarcoidosis is a granulomatous disease that can affect many organs.  Most of us have heard of pulmonary manifestation and lymph nodes involvement.  The classic Lofgren’s syndrome consists of arthritis, erythema nodosum, bilateral hilar adenopathy.  This occasionally shows up in Medical Jeopardy and morning reports.

Cardiac infiltration most commonly occurs in LV free wall, intraventricular septum, and conduction system.  Because of this, it may manifest as:

- conduction abnormality and dysrhythmias (palpitations, syncope, sudden death)

- cardiomyopathy (heart failure symptoms such as dyspnea, orthopnea, peripheral edema)

But another reason for patients with sarcoidosis to have heart failure is right heart failure secondary to their pulmonary disease, as well as valvular regurgitation (especially MR from papillary muscle dysfunction).  Pericardial diseases are rare but have been reported.

As we discussed and saw in our patient today, echocardiography and cardiac MRI are important imaging modalities in these patients.

Also discussed in morning report today, aggressive investigation of dysrhythmias and pace-maker/ICD implantation is usually recommended if electrical system involved.  Treatment of sarcoidosis with corticosteroids for heart failure is usually warranted.

We did not really touch on this today, but for general management of heart failure, we refer you to the Canadian Cardiovascular Society Heart Failure Guideline program here.

Thank you for a great morning report and have a thrilling Thursday!