Cardiac Involvement In Sarcoidosis Research Articles

Assessment of a new index of myocardial strain for the diagnosis of cardiac sarcoidosis

Abstract Background The diagnosis of cardiac involvement in sarcoidosis is challenging and often expensive. Purpose The aim of this study is to assess whether a new strain index proposed by the authors has incremental value in the evaluation of cardiac involvement, compared to the use of left ventricular (LV) global longitudinal strain (GLS). Methods This is a single-center, non-blinded, pilot cross-sectional study. Patients of both genders, >18 years old, with confirmed diagnosis of cardiac sarcoidosis according to the Heart Rhythm Society criteria, and controls consisting of individuals diagnosed with systemic sarcoidosis without cardiac involvement, were included. Patients with obesity grade 2 or higher , moderate or severe primary heart valve disease, myocardial diseases of other etiologies, established coronary artery disease, and inadequate acoustic window were excluded. All patients underwent transthoracic echocardiography, with subsequent measurements performed on a workstation. The following LV indexes were evaluated: GLS and the new proposed index, calculated by the ratio between LVEF and the sum of the two segments with the lowest absolute strain values. ROC curves were calculated for both parameters using an online dedicated software, with determination of the optimal cutoff point for both variables, corresponding to the point of highest sensitivity and specificity. Confidence intervals were established by the DeLong method, and curves were compared using the Bonferroni method. A two-tailed p value of 0.05 was considered significant. Results Twenty patients with cardiac involvement and twenty patients without cardiac involvement were evaluated. The results of the variables are presented in table 1. Conclusions The new index showed a larger area under the curve compared to isolated GLS, as well as higher sensitivity and specificity for the identified cutoff point, although without statistical significance, possibly due to the small sample size. Further studies are needed for subsequent validation of this innovative index.

The Many Faces of Cardiac Involvement in Sarcoidosis

The Many Faces of Cardiac Involvement in Sarcoidosis

Exploring the Intersection of Sarcoidosis and Cardiac Arrhythmias

Sarcoidosis is a multi-organ granulomatous disease of uncertain origin, characterized by the formation of non-necrotizing granulomas in various organs, including the heart. Cardiac involvement in sarcoidosis is rare, with approximately 5% of sarcoidosis patients developing clinically apparent cardiac disease, which is associated with significant morbidity and mortality. Genetically predisposed individuals develop granuloma in myocardium musculature, leading to aberrant conduction of cardiac impulses and the development of various arrhythmias. Common arrhythmias range from atrial fibrillation to ventricular tachycardia and can lead to sudden cardiac death because of ventricular fibrillation. The diagnostic challenge results from high specificity but rather limited sensitivity of endomyocardial biopsy, which is the gold standard diagnostic test, making advanced imaging techniques, such as cardiac magnetic resonance imaging and fluorine-18 fluorodeoxyglucose positron emission tomography, crucial for early detection. Management involves a complex approach with immunosuppression, antiarrhythmic medications, and catheter ablation, often supplemented by implantable cardioverter-defibrillators to prevent sudden cardiac death. In cardiac sarcoidosis, ventricular arrhythmias are common and cause high mortality. Timely intervention and management are crucial for a better prognosis. The disease's growing prevalence requires further research on refining early detection techniques and developing efficient treatment strategies for these high-risk patients. This review focuses on the etiopathogenesis of arrhythmias in cardiac sarcoidosis, diagnosis, and effective management strategies.

A Comprehensive Review on the Electrocardiographic Manifestations of Cardiac Sarcoidosis: Patterns and Prognosis.

Cardiac sarcoidosis (CS) refers to cardiac involvement in sarcoidosis and is usually associated with worse outcomes. This comprehensive review aims to elucidate the electrocardiographic (ECG) signs and features associated with CS, as well as examine modern techniques and their importance in CS evaluation. The exact pathogenesis of CS is still unclear, but it stems from an abnormal immunological response triggered by environmental factors in individuals with genetic predisposition. CS presents with non-cardiac symptoms; however, conduction system abnormalities are common in patients with CS. The most common electrocardiographic (ECG) signs include atrioventricular blocks and ventricular tachyarrhythmia. Distinct patterns, such as fragmented QRS complexes, T-wave alternans, and bundle branch blocks, are critical indicators of myocardial involvement. The application of advanced ECG techniques such as signal-averaged ECG, Holter monitoring, wavelet-transformed ECG, microvolt T-wave alternans, and artificial intelligence-supported analysis holds promising outcomes for opportune detection and monitoring of CS. Timely utilisation of inexpensive and readily available ECG possesses the potential to allow early detection and intervention for CS. The integration of artificial intelligence models into ECG analysis is a promising approach for improving the ECG diagnostic accuracy and further risk stratification of patients with CS.

Trends and Disparities in Cardiovascular Death in Sarcoidosis: A Population-Based Retrospective Study in the United States From 1999 to 2020.

Despite significant cardiac involvement in sarcoidosis, real-world data on death due to cardiovascular disease among patients with sarcoidosis is not well established. We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database for data on patients with sarcoidosis aged ≥25 years from 1999 to 2020. Diseases of the circulatory system except ischemic heart disease were listed as the underlying cause of death, and sarcoidosis was stated as a contributing cause of death. We calculated age-adjusted mortality rate (AAMR) per 1 million individuals and determined the trends over time by estimating the annual percentage change using the Joinpoint Regression Program. Subgroup analyses were performed on the basis of demographic and geographic factors. In the 22-year study period, 3301 cardiovascular deaths with comorbid sarcoidosis were identified. The AAMR from cardiovascular deaths with comorbid sarcoidosis increased from 0.53 (95% CI, 0.43-0.65) per 1 million individuals in 1999 to 0.87 (95% CI, 0.75-0.98) per 1 million individuals in 2020. Overall, women recorded a higher AAMR compared with men (0.77 [95% CI, 0.74-0.81] versus 0.58 [95% CI, 0.55-0.62]). People with Black ancestry had higher AAMR than people with White ancestry (3.23 [95% CI, 3.07-3.39] versus 0.39 [95% CI, 0.37-0.41]). A higher percentage of death was seen in the age groups of 55 to 64 years in men (23.11%) and women (21.81%), respectively. In terms of US census regions, the South region has the highest AAMR from cardiovascular deaths with comorbid sarcoidosis compared with other regions (0.78 [95% CI, 0.74-0.82]). The increase of AAMR from cardiovascular deaths with comorbid sarcoidosis and higher cardiovascular mortality rates among adults aged 55 to 64 years highlight the importance of early screening for cardiovascular diseases among patients with sarcoidosis.

Persistent Anterior Thoracalgia in a Patient with Mediastinal - Pulmonary Sarcoidosis

Abstract Sarcoidosis is a systemic condition characterized by the formation of non-caseating granulomas in any organ or tissue, with a predominant impact on the lungs and intrathoracic lymph nodes(1). The heterogeneity of the disease is reflected in the broad possibilities of the clinical and paraclinical evolution, which can range from the incidental identification of the disease in an asymptomatic patient to the progressive chronic involvement of the affected organs. Commonly, sarcoidosis initially manifests through nonspecific respiratory symptoms, characterized by dry cough, dyspnea, chest pain, and fatigue(2,3). Generally, it is considered that this condition occurs in individuals with a susceptible genetic background, exposed to certain environmental factors or antigens that remain unknown, despite numerous existing hypotheses(4). Cardiac involvement in sarcoidosis has a significant negative impact on prognosis. Although this location of the disease is predominantly silent, 5% of cases present with dilated or restrictive cardiomyopathy, progressive heart failure, high-grade atrioventricular blocks, and ventricular arrhythmias(5). The authors present the case of a young patient who, although at the onset of the disease, exhibited a typical clinical and imaging profile of sarcoidosis, myocardial involvement - a rare localization of this pathology - was detected during the course of the condition. Patients with sarcoidosis may have normal spirometry, may present with a restrictive syndrome (similar to diffuse interstitial lung diseases), or an obstructive syndrome, secondary to the involvement of small bronchi and bronchial distortions caused by the disease, often with an unfavorable prognosis.

Typical trident sign and cardiac involvement in a patient suspected to Sarcoidosis despite negative whole-body FDG-PET: a case report

BackgroundSarcoidosis is a systemic inflammatory disease histologically defined by the non-caseation granulomas formation in different organs, most commonly lungs, liver, skin, gastrointestinal system, eyes, neurologic and cardiac systemCase presentationWe report the case of a 42-year-old Gilaks woman who presented with myelopathy with characteristic MRI finding called trident sign. By finding this view in axial spinal Magnetic Resonance Imaging (MRI) imaging, a systemic evaluation was performed on the patient, which led to the diagnosis of cardiac involvement in Sarcoidosis with the specific appearance of this disease in cardiac MRI despite the negative Fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan.ConclusionsSometimes characteristic findings such as the trident sign prompt the physician to high suspicion and wide evaluation of the patient to reveal important organ involvement that changes the treatment decision and saves the patient.

Abstract 12991: Geographical Disparities in Cardiovascular Death in Sarcoidosis

Background: While cardiac involvement in sarcoidosis could be significant, data assessing geographical disparities in cardiovascular deaths (CVDs) among patients with sarcoidosis are limited. Objective: This study aims to determine the mortality attributed to CVDs with comorbid sarcoidosis in different geographic locations in the United States. Methods: We queried the Centers for Disease Control and Prevention's Wide-Ranging Online Data for Epidemiologic Research database and performed serial cross-sectional analyses of national death certificate data for CVDs with comorbid sarcoidosis among patients aged 25 and above. Diseases of the circulatory system (ICD-10 I00-I99) were listed as the underlying cause of death, and sarcoidosis (ICD-10 D86) as contributing cause of death. We calculated age-adjusted mortality rates (AAMRs) per 1,000,000 individuals and compared the mortality among census regions and states. Results: In the 22-year study period, 5,630 CVDs with comorbid sarcoidosis in the United States were identified between 1999 and 2020. The South region had the highest AAMRs for CVDs with comorbid sarcoidosis (1.32 [95% CI, 1.26-1.37] per 1,000,000 individuals), followed by Northeast region (1.25 [95% CI, 1.18-1.32] per 1,000,000 individuals), Midwest region (1.24 [95% CI, 1.17-1.30] per 1,000,000 individuals), and West Region (0.92 [95% CI, 0.86-0.98] per 1,000,000 individuals). The AAMRs for CVDs with comorbid sarcoidosis were between 0.57 [95% CI, 0.43-0.75] per 1,000,000 individuals and 1.96 [95% CI, 1.73-2.19] per 1,000,000 individuals throughout the States, except Maryland and the District of Columbia, which recorded 2.79 [95% CI, 2.44-3.14] and 6.01 [95% CI, 4.44-7.94], respectively. Conclusion: The South region, particularly Maryland recorded the highest CVDs in sarcoidosis. Geographical disparities observed in CVDs with comorbid sarcoidosis highlight the need to improve public health measures at state-level.

Serial assessment of cardiac involvement in sarcoidosis by delayed 18F-fluorodeoxyglucose PET/CT

Serial assessment of cardiac involvement in sarcoidosis by delayed 18F-fluorodeoxyglucose PET/CT

Cardiac sarcoidosis: is early diagnosis possible? Case report

Cardiac involvement in sarcoidosis is difficult to diagnose due to the asymptomatic course in 95% of cases, the inaccessibility and low information content of a heart biopsy, the absence of pathological disorders in routine examination methods or their non-specificity. At the same time, it is cardiac sarcoidosis, along with damage to the nervous system, that is the main cause of mortality in sarcoidosis. Early diagnosis is of decisive importance for preventing complications associated with heart involvement and choosing the right treatment tactics. The positron emission tomography-computed tomography (PET-CT) is a method that can help the doctor in assessing the prevalence of sarcoidosis and verifying latent localizations in patients with a morphologically confirmed disease. The article describes a case of the use of PET/CT for the diagnosis of cardiac sarcoidosis.

A nationwide analysis of cardiac sarcoidosis and related in-hospital outcomes

Abstract Introduction Sarcoidosis is a multisystem disorder characterized by an autoimmune response to an unidentified antigen in genetically susceptible persons. Despite clinically detectable cardiac manifestations of sarcoidosis occurring in approximately 5% of patients, recent studies have revealed cardiac involvement to be at 25% in patients with the disease, highlighting the fact that cardiac involvement in sarcoidosis is much more common than was once thought to be. Purpose With cardiac involvement in sarcoidosis being increasingly recognized due to the availability of advanced cardiac imaging, large scale data regarding in-hospital mortality and clinical outcomes of patients admitted with cardiac sarcoidosis (CS) is lacking. Our study aimed to fill this knowledge gap by analyzing demographics and in-hospital outcomes of a large cohort of patients admitted with CS across the United States (US). Methods We analyzed data from the national inpatient sample (NIS) database between October 2015 to December 2018 to identify patients who had been admitted with primary and secondary diagnoses of CS. The NIS is an administrative database sponsored by the Agency for Healthcare Research and Quality consisting of data from 46 participating states, representing more than 95% of the US population and providing nationwide estimates of over 35 million hospitalizations annually. The NIS uses de-identified hospital discharges as samples and hence no additional ethical committee approval was required. International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) code D86.85 was used to identify hospitalizations with CS in patients aged 18 years or older. SAS 9.4 (SAS Institute, Inc, Cary, NC) was used for statistical analyses. Results A total of 4275 patients were included in the analysis. A higher proportion of patients with CS were females (62.43% vs. 37.57%). Hypertension was the most common comorbidity (43.99%), followed by hyperlipidemia (39.21%) and chronic kidney disease (26.95%). All-cause in-hospital mortality was 2.57%. Atrial fibrillation (AF) was the most common arrhythmia (28.12%), followed by ventricular tachycardia (VT) (22.52%). About 16% of CS patients underwent implantable cardioverter-defibrillator (ICD) implantation during hospital stay. About 42% of patients had concurrent heart failure, out of whom 33.84% had heart failure with reduced ejection fraction (HFrEF). Mean length of hospital stay was 5 days (3–8 days), and the mean cost of hospitalization was $14,177 ($7,121–35,993). Conclusion Given the low prevalence of CS, most of the available studies have been retrospective in nature, based on small sample sizes. Despite being retrospective and cross-sectional, our study has the advantage of being based on a nationally representative sample population, providing key formation on the demographics and in-hospital outcomes of patients with CS. Funding Acknowledgement Type of funding sources: None.

Hybrid PET/MRI for inflammatory cardiomyopathy

HintergrundDie Myokarditis und die inflammatorische Kardiomyopathie sind aufgrund ihrer unterschiedlichen Auslöser, Phänotypen und Stadien diagnostisch häufig schwer zu diagnostizieren.Methodische Innovationen und ProblemeDie kardiale Positronen-Emissions-Tomographie/Magnetresonanztomographie (PET/MRT) zeichnet sich neben der myokardialen Gewebecharakterisierung mittels MRT durch den möglichen Nachweis einer aktiven myokardialen Entzündung (Inflammation) mittels PET aus. Die Kombination von MRT und PET ist somit eher synergistisch als rein summativ: Die möglicherweise in der MRT vorhandenen kardialen Veränderungen lassen sich durch die PET in aktive inflammatorische (und somit noch potenziell reversible) Prozesse oder ältere chronische (irreversible) Narben unterscheiden. Die kardiale Sarkoidose mit einem potenziellen Nebeneinander von aktiven und chronischen Veränderungen bietet sich an, um die Stärken einer hybriden PET/MRT zur Geltung bringen zu lassen. Wichtig für eine aussagekräftige kardiale PET ist eine gute Vorbereitung mit Low-Carb-Diät, um eine suffiziente Suppression der myokardialen Glukoseaufnahme zu gewährleisten.EmpfehlungenDie Diagnostik einer inflammatorischen Herzerkrankung sowie deren Charakterisierung in akut vs. chronische Prozesse gelingt mit der kardialen Hybrid-PET/MRT, wie am Beispiel der kardialen Sarkoidose gezeigt werden konnte.

Risk of Sudden Death in a General Unbiased Epidemiological Cohort of Sarcoidosis.

BackgroundSarcoidosis is an inflammatory, noncaseating, granulomatous disorder of unknown cause that can affect any body system and is associated with cardiovascular disease including sudden cardiac death (SCD). Cardiac involvement in sarcoidosis is associated with higher risk of SCD, but the SCD risk in the general sarcoidosis population is unknown. We aimed to determine the risk of SCD in people with sarcoidosis versus the matched general population.Methods and ResultsA population‐based cohort of sarcoidosis and age‐ and sex‐matched comparators from January 1, 1976 to December 31, 2013 was used; presence of other comorbidities in the comparator group was not an exclusion criterion. Mortality, including time, place, and cause of death were measured and manually adjudicated for SCD events. Incidence rates are reported per 100 000 person‐years, and Cox models were used for group comparisons. Of the 345 incident cases of sarcoidosis (171 men; 50%) there were 58 reported deaths; 10 were definite/probable SCD versus 57 all‐cause and 9 SCDs in comparators. Median follow‐up was 12.9 years (interquartile range, 6.0–23.4 years) . Incidence rate of SCD in sarcoidosis was 192 (95% CI, 92–352) versus 155 (95% CI, 71–294) in comparators (hazard ratio [HR], 1.28 (95% CI, 0.52–3.17). Nocturnal deaths were more frequent in sarcoidosis 57 (95% CI, 12–168) versus 17 (95% CI, 0.4–95) (HR, 3.76 [95% CI, 0.39–36.47]). No significant differences were detected between the groups by sex, age, calendar year of diagnosis, or disease duration.ConclusionsIn a population‐based cohort of patients with sarcoidosis, the risk for SCD compared with matched comparators was not increased. There were more nocturnal deaths among patients with sarcoidosis, yet this was statistically insignificant.

Real-time three-dimensional echocardiography for detection of cardiac sarcoidosis in the early stage: a cross-sectional single-centre study

Background Sarcoidosis with cardiac involvement has a relatively high morbidity and mortality, and early diagnose of cardiac sarcoidosis is a critical issue. Systolic dyssynchrony index (SDI) measured by three-dimensional echocardiography was used in our study for detection of subclinical left ventricular (LV) systolic dysfunction in patients with sarcoidosis and normal LV function on two-dimensional echocardiography. Methods Forty-four patients diagnosed with sarcoidosis (without clinically apparent cardiac involvement) and 44 healthy control subjects were included in this study. Two-dimensional echocardiographic parameters, also LV volumes and SDI measured by 3D echocardiography were analyzed in all participants. Results While two-dimensional echocardiographic results of both study groups were similar; SDI_16 (SDI for 16 segments of LV) results were significantly higher in sarcoidosis group compared to healthy controls (6.99 ±5.02 vs 2.89 ± 1.32, p < 0.0001). Conclusion SDI_16 was higher in patients with sarcoidosis compared to healthy controls probably due to patchy infiltration characteristic of the disease. This parameter could be used as a marker to identify patients with cardiac involvement of sarcoidosis in the early phase.

Peripheral blood natural killer cells in sarcoidosis are associated with early cardiac involvement

To evaluate the distribution of circulating immune cell subsets in peripheral blood of patients with sarcoidosis and investigate if there is an association with an underlying cardiac involvement. Eighty-five newly diagnosed treatment-naïve patients with sarcoidosis (50 women) were included in the study. All patients underwent a thorough cardiac investigation, including cardiac magnetic resonance imaging (CMR). Of all patients, 19 (23.53%) had myocardial involvement, and the NK subpopulation in these patients in peripheral blood was significantly decreased compared to patients without (n=63, p=0.001 and p=0.003 respectively). The absolute number of NKT cells (CD3+CD16/56+ ) in patients with cardiac involvement was highly correlated with T2map increased values in MRI (r=-686, p=0.041) showing that low NKT cell count correlates with the inflammatory process of the heart. No difference in CD19, CD3, CD4, CD8 and CD3- NK cell counts was found between groups. Lung severity was not found to correlate with the number of NK cells. We found that low NK cell count in peripheral blood of patients with sarcoidosis is associated with cardiac involvement, and the number of NK-T cells correlates with CMR findings indicative of myocardial inflammation. This finding might have a potential clinical application in detecting clinically silent cardiac involvement in sarcoidosis and may also suggest potential targets for therapeutic interventions.

PET Imaging in Cardiac Sarcoidosis: A Narrative Review with Focus on Novel PET Tracers.

Sarcoidosis is a multi-system inflammatory disease characterized by the development of inflammation and noncaseating granulomas that can involve nearly every organ system, with a predilection for the pulmonary system. Cardiac involvement of sarcoidosis (CS) occurs in up to 70% of cases, and accounts for a significant share of sarcoid-related mortality. The clinical presentation of CS can range from absence of symptoms to conduction abnormalities, heart failure, arrhythmias, valvular disease, and sudden cardiac death. Given the significant morbidity and mortality associated with CS, timely diagnosis is important. Traditional imaging modalities and histologic evaluation by endomyocardial biopsy often provide a low diagnostic yield. Cardiac positron emission tomography (PET) has emerged as a leading advanced imaging modality for the diagnosis and management of CS. This review article will summarize several aspects of the current use of PET in CS, including indications for use, patient preparation, image acquisition and interpretation, diagnostic and prognostic performance, and evaluation of treatment response. Additionally, this review will discuss novel PET radiotracers currently under study or of potential interest in CS.

Cardiac involvement in sarcoidosis: Evolving concepts in diagnosis and treatment

Clinically evident cardiac involvement has been noted in at least 2 to 7% of patients with sarcoidosis, but occult involvement is much higher (&gt; 20%). Cardiac Sarcoidosis (CS) is often not recognized as an antemortem, as sudden death may be the presenting feature. Cardiac involvement may occur at any point during the course of sarcoidosis and may occur in the absence of pulmonary or systemic involvement. Sarcoidosis can involve any part of the heart. The prognosis of CS is related to the extent and site(s) of involvement. Most deaths due to CS are due to arrhythmias or conduction defects, but granulomatous infiltration of the myocardium may cause progressive and ultimately lethal cardiomyopathy. The definitive diagnosis of isolated CS is difficult and the yield of Endomyocardial Biopsies (EMB) is low. Treatment of CS is often warranted even in the absence of histologic proof. Radionuclide scans are integral to the diagnosis. Gadolinium-enhanced cardiac magnetic imaging scans and 18Fluorodeoxyglucose (18FDG)-Positron Emission Tomography (PET) are the key imaging modalities to diagnose CS. The prognosis of CS is variable, but mortality rates of untreated CS are high. Randomized therapeutic trials have not been done, but corticosteroids (alone or combined with additional immunosuppressive agents) are the mainstay of therapy. Additionally, anti-arrhythmic agents and therapy for heart failure are often required. Because of the potential for sudden cardiac death, an Implantable Cardioverter-Defibrillator (ICD) should be placed in any patient with CS and serious ventricular arrhythmias or heart block and should be considered for cardiomyopathy. Cardiac transplantation is a viable option for patients with end-stage CS refractory to medical therapy.

EP News: Case Reports

Sarcoidosis is a granulomatous disease that can present broadly from multisystem disease to very focal manifestations, including as ventricular tachycardia (VT) in the setting of cardiac involvement. With improved awareness of the intersection of inflammatory triggers and substrate in patients who present with VT, the spectrum of cardiac involvement in sarcoidosis has been expanded. Ando et al (https://doi.org/10.1016/j.hrcr.2021.08.014) shared a case of a 50-year-old man presented with frequent premature ventricular complexes (PVCs) (right bundle branch block morphology and an rS pattern in the inferior leads and lead V6, suggestive of a posteromedial papillary muscle origin) on routine clinical examination.

Delayed 18F-fluorodeoxyglucose PET/CT imaging improves detection of cardiac involvement in sarcoidosis

Delayed 18F-fluorodeoxyglucose PET/CT imaging improves detection of cardiac involvement in sarcoidosis

Diagnosis of cardiac sarcoidosis: a primer for non-imagers.

Sarcoidosis is a multisystem granulomatous disorder that can potentially involve any organ. Cardiac involvement in sarcoidosis has been reported in up to 25% of patients based on autopsy and imaging studies. The gold standard for diagnosing cardiac sarcoidosis is endomyocardial biopsy demonstrating non-caseating granulomas; however, this technique lacks sensitivity due to the patchy nature of myocardial involvement. This, along with the non-specific clinical presentation, renders the diagnosis of cardiac sarcoidosis extremely challenging. Difficulties in obtaining histopathologic diagnosis and the advances in imaging modalities have led to a paradigm shift toward non-invasive imaging in the diagnosis of cardiac sarcoidosis. Advances in cardiac imaging modalities have also allowed unprecedented insights into the prevalence and natural history of cardiac sarcoidosis. This review discusses the role of non-invasive imaging for diagnosis, risk stratification, and monitoring the response to therapies in cardiac sarcoidosis. Echocardiography remains the first-line modality due to widespread availability and affordability. Cardiac magnetic resonance imaging (CMR) can be used to study cardiac structure, function, and most importantly tissue characterization to detect inflammation and fibrosis. Fluoro-deoxy glucose positron emission tomography (FDG PET) is the gold standard for non-invasive detection of cardiac inflammation, and it offers the unique ability to assess response to therapeutic interventions. Hybrid imaging is a promising technique that allows us to combine the unique strengths of CMR and FDG PET. Understanding the advantages and disadvantages of each of these imaging modalities is crucial in order to tailor the diagnostic algorithm and utilize the most appropriate modality for each patient.