Abstract 11916: An Elusive and Unusual Diagnosis of Cardiac Sarcoidosis

Introduction: Cardiac sarcoidosis (CS) can present heterogeneously; presentations are often related to conduction system abnormalities in the form of AV block or ventricular arrhythmia, or heart failure. There are not yet widely accepted diagnostic guidelines for CS although diagnostic pathways such as the Japanese Ministry of Health and Welfare and the Heart Rhythm Society criteria exist.

Methods: A 65 year old female with a history of hypertension, HFpEF, CAD with remote DES to RCA, CKD3a, Obesity and biopsy proven pulmonary sarcoidosis presented with 3 days of sudden onset dyspnea and hypoxia. Labs included aa pro-BNP of 16,754 pg/mL (0-299) and high-sensitivity troponin of 35 ng/L (0-14). EKG showed sinus rhythm with left axis and QTc of 499 ms. Chest Xray revealed pulmonary edema consistent with heart failure exacerbation Echocardiogram revealed EF 60-64%, normal LV and RV wall motion and thickness, and GLS of-17.2%. Left heart catheterization revealed patent RCA stent and non-obstructive CAD. She was diuresed to euvolemic state. Inpatient cardiac monitoring, repeat EKGs, and an 8 day holter monitor showed no arrhythmia or conduction abnormality. Although clinical suspicion for CS was low due lack of arrhythmia, preserved EF and several independent risk factors for HFpEF. FDG-PET was performed to rule out CS and revealed defects in basal anteroseptal and apical lateral regions consistent with sarcoid related fibrosis (Figure 1). Disseminated disease was seen in mediastinal and splenic regions. The patient was started on prednisone and methotrexate therapy for immunosuppressive treatment of CS.

Conclusions: In patients with known sarcoidosis, a high index of suspicion for CS is required due to lack of clear diagnostic guidelines. Although diagnostic criteria frequently highlight systolic heart failure and arrhythmias, CS can present in patients with HFpEF, and the presence of other risk factors for diastolic heart failure should not preclude CS investigation.