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Optimizing routine screening for cardiac sarcoidosis through use of commonly available studies
Arthur W Holtzclaw1, Zorana Mrsic2, Tyler L Church1
1Walter Reed National Military Medical Center, Pulmonary and Critical Care, USA.
Insights
Cardiac sarcoidosis (CS) is underdiagnosed. Current screening guidelines lack sensitivity. A modified screening approach including ambulatory rhythm monitoring significantly improves detection rates for CS.
Area of Science:
- Cardiology
- Pulmonology
- Immunology
Background:
- Sarcoidosis is a multisystem disorder with variable organ involvement.
- Cardiac sarcoidosis (CS) presents a high mortality risk and is frequently underdiagnosed.
- Current screening guidelines from the Heart Rhythm Society (HRS) and American Thoracic Society (ATS) have limitations due to sparse supporting data.
Purpose of the Study:
- To assess the prevalence of abnormal screening tests in sarcoidosis patients.
- To evaluate the correlation between screening tests and the diagnosis of CS.
- To compare the sensitivity of existing recommendations versus a modified screening criteria for CS detection.
Main Methods:
- Retrospective analysis of prospectively enrolled patients from a tertiary military academic center.
- Correlation of advanced imaging (cardiac MRI/FDG-PET) with screening studies (symptom screen, EKG, TTE, ambulatory rhythm monitoring).
- Calculation of sensitivity, specificity, and predictive values for HRS criteria and a modified rubric including ambulatory rhythm monitoring.
Main Results:
- The study included 114 sarcoidosis patients with 132 advanced imaging events, diagnosing CS in 36 patients.
- The Heart Rhythm Society (HRS) screening recommendations showed a sensitivity of 63.9% for CS detection.
- A modified screening criteria, incorporating ambulatory rhythm monitoring, increased sensitivity to 94.4%.
Conclusions:
- Existing Heart Rhythm Society (HRS) guidelines demonstrate insufficient sensitivity for effective cardiac sarcoidosis (CS) screening.
- A modified screening model incorporating ambulatory rhythm monitoring offers improved diagnostic efficacy for CS.
- Further research is warranted to refine screening protocols for CS.
Background:
Sarcoidosis is a multisystem granulomatous disorder with unclear etiology. Morbidity and mortality vary based on organ involvement, with cardiac sarcoidosis (CS) associated with higher mortality; despite this, CS remains underdiagnosed. The Heart Rhythm Society (HRS) expert consensus statement recommends screening sarcoidosis patients for CS utilizing a symptom screen, EKG, and echocardiogram (TTE), while the American Thoracic Society (ATS) guideline recommends only EKG and symptom screening. These recommendations, however, are based on limited data with recommendations for further studies.
Research Question:
The purpose is to evaluate the prevalence of abnormal screening tests in patients with sarcoidosis and the correlation of these tests with the subsequent diagnosis of CS. A specific emphasis was placed on evaluating the sensitivity of the recommendations versus the sensitivity of a modified criteria.
Study Design:
and Methods: This study retrospectively evaluated a database of prospectively enrolled patients from a tertiary military academic center. All patients who underwent imaging with cardiac MRI and/or FDG-PET were identified. These results were correlated with screening studies (symptom screen, EKG, TTE, and ambulatory rhythm monitoring (ARM)) and used to calculate sensitivity, specificity, and positive and negative predictive values for each test. Using a clinical diagnosis of CS as the reference standard, the sensitivity and specificity of the HRS criteria were calculated and compared to a modified screening rubric developed a priori, consisting of minor changes to the criteria and the addition of ARM.
Results:
This study evaluated 114 patients with sarcoidosis with 132 advanced imaging events, leading to a diagnosis of CS in 36 patients. Utilizing HRS screening recommendations, the sensitivity for CS was 63.9%, while the modified criteria increased sensitivity to 94.4%.
Interpretation:
This study suggests that the HRS guidelines lack sensitivity to effectively screen for CS and that a modified screening model which includes ARM may be more effective.
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