Time Course and Factors Correlating With Ventricular Tachyarrhythmias After Introduction of Steroid Therapy in Cardiac Sarcoidosis

Abstract

Background— The time course and factors correlating with ventricular tachyarrhythmias (VTs) after introduction of corticosteroid therapy in patients with cardiac sarcoidosis remain to be elucidated. Methods and Results— We examined 68 consecutive patients with cardiac sarcoidosis in the Tohoku University Hospital from October 1998 to September 2014 (age: 57±11 years old; male:female 18:50) and evaluated VTs after initiation of steroid therapy. VTs were defined as documented ventricular tachycardia or ventricular fibrillation lasting for more than 30 seconds or resulting in cardiovascular collapse, or appropriate implantable cardioverter defibrillator therapy. During a mean follow-up of 5.5 years, 20 out of 68 patients (29%) experienced VTs after initiation of corticosteroid therapy, especially in the first 12 months in 14 patients (70%). A multivariable analysis revealed that positive gallium scintigraphy had a significant correlation with VTs (hazard ratio, 11.33; 95% confidence interval, 3.22–39.92; P <0.001), in addition to reduced left ventricular ejection fraction (hazard ratio, 0.94; 95% confidence interval, 0.90–0.97; P =0.001). Furthermore, electrical storm was noted in 10 patients (14.7%), 8 within the first 12 months of treatment, whereas the recurrence of electric storm was relatively less. Conclusions— These results indicate that VTs and electric storm frequently occur in the first 12 months after initiation of corticosteroid therapy, presumably because of inflammatory conditions, and that the positive gallium scintigraphy is a significant and independent predictor of VTs. The present findings may be useful to further improve the management of VTs in patients with cardiac sarcoidosis.

Cardiac sarcoidosis: diagnosis and management

“…Corticosteroids and antiarrhythmic drugs are initiated together for VTs when active inflammation is evident (Jefic et al, 2009), while catheter ablation and cardioverter defibrillator implantation are suggested if VT cannot be controlled (Naruse et al, 2014;Segawa et al, 2016). Amiodarone and sotalol are classic choices, although VTs are frequently resistant.…”

Strategies for Managing Arrhythmias in Patients with Cardiac Sarcoidosis

“…Ventricular arrhythmias are a common manifestation of cardiac sarcoidosis and are more likely to occur in patients with infra-Hisian conduction disease and/or depressed EF. 34 Although triggered activity and enhanced automaticity can result in frequent ventricular ectopy that is responsive to immunosuppression, 35,36 the majority of ventricular arrhythmias are believed to be reentrant arrhythmias around scar tissue. 37,38 Treatment involves a combination of immunosuppression, antiarrhythmic drug therapy, and radiofrequency ablation.…”

“…Data on the efficacy of immunosuppression in treating ventricular tachycardia (VT) are scant and at times contradictory, likely representing a heterogeneous collection of patients and disease states. 34,39 The study of Yodogawa et al 36 of 31 patients with cardiac sarcoidosis and ventricular arrhythmias demonstrated that patients with less severe disease, as measured by EF, responded better to steroids than did those with more severely depressed EFs. As steroids reduce inflammation, these results are in agreement with a management strategy of using aggressive immunosuppression early in the disease process to prevent fibrosis.…”

“…Unfortunately, patients with more advanced disease may see an increase in arrhythmias following the initiation of steroids. The study of Segawa et al 34 of 68 patients with cardiac sarcoidosis who were started on corticosteroids demonstrated that 20 patients (29%) went on to develop ventricular arrhythmias after the initiation of steroids. It is unclear as to whether the emergence of ventricular arrhythmias after the initiation of steroids was due to immunomodulation or more aggressive disease.…”

“…It is unclear as to whether the emergence of ventricular arrhythmias after the initiation of steroids was due to immunomodulation or more aggressive disease. 34…”