Redefining Cardiac Sarcoidosis with Advanced Imaging and Therapeutic Strategies

Cardiac sarcoidosis (CS) is an elusive, yet potentially life-threatening disease marked by granulomatous inflammation of the myocardium, which can lead to arrhythmias, heart failure, and sudden cardiac death. Although corticosteroids have long been the mainstay of treatment, the therapeutic landscape is rapidly evolving. Recent insights have underscored the role of alternative immunosuppressants and biologic agents in enhancing disease control while minimizing long-term toxicity. Advances in imaging, particularly cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (18F-FDG PET) are transforming both diagnosis and follow-up, enabling earlier detection and personalized monitoring of therapeutic response. At the same time, arrhythmia management and device implantation, especially implantable cardioverter-defibrillators (ICDs), have become central to risk stratification and prevention of fatal outcomes. This review explores the latest developments in the management of CS, highlighting a paradigm shift toward integrated, multidisciplinary care. From immunomodulation to advanced imaging and electrophysiological strategies, we emphasize the importance of tailoring interventions to disease severity and patient risk. Special focus is given to high-risk cases and evolving criteria for heart transplantation, grounded in the most up-to-date clinical evidence.