MRI scans of heart may predict relapse risk with cardiac sarcoidosis
Likelihood five times higher if more scar tissue evident before treatment
MRI scans of the heart may help in predicting the risk of cardiac sarcoidosis recurring after initial successful treatment, a study reports.
A greater extent of scarred heart tissue prior to treatment, in particular, was associated with a five times higher risk of relapse. The presence of sarcoidosis only involving the heart also linked with a greater likelihood of disease recurrence.
“To the best of our knowledge, this is the first study to show a correlation between quantified disease burden on MRI and incremental risk of relapse” in cardiac sarcoidosis, researchers wrote.
The study, “Incidence and Predictors of Relapse After Weaning Immune Suppressive Therapy in Cardiac Sarcoidosis,” was published in The American Journal of Cardiology.
Cardiac sarcoidosis found in up to 25% of all with this autoimmune disease
Sarcoidosis is an autoimmune disease characterized by clumps of inflammatory immune cells that can affect various organs. Up to 1 in 4 of these patients have cardiac sarcoidosis, where the disease affects the heart.
Standard disease treatment involves anti-inflammatory therapies such as corticosteroids. Typically, patients initially are given somewhat high doses to fully suppress the inflammation that drives the disease. Then, once cardiac sarcoidosis is under control, referred to as remission, anti-inflammatories either move to much lower doses or are stopped entirely. This helps to prevent the problematic side effects associated with long-term use of these treatments.
After patients achieve remission, however, some experience a disease recurrence that necessitates additional rounds of high-dose anti-inflammatory treatments. Little is known as to exactly how common such relapses are, or what factors may increase their risk among cardiac sarcoidosis patients in remission.
Researchers reviewed of data covering 68 cardiac sarcoidosis patients treated at their Duke University Medical Center between 2000 and 2020.
“We sought to describe, in a modern cohort, the incidence of clinical relapse and demographic and clinical factors associated with increased risk of relapse,” the scientists wrote.
Among the patients, 37% were women, 47% were Black, and the average age at starting anti-inflammatory treatment was 50.7 years. For most (76%), sarcoidosis also was affecting organs outside the heart.
After initial treatment with high-dose corticosteroids or other anti-inflammatory medications, 59 (87%) went into remission, either not requiring any treatment or needing only low doses of medications as maintenance therapy. The median time from starting treatment to achieving remission was 10.2 months.
Most of the patients in remission were followed for more than three years. During those years, nearly half — 28 of 59 patients, or 48% — experienced a disease relapse, with newly worsening symptoms such as abnormal heart rhythms (arrhythmia) or heart failure, where the heart is unable to adequately pump blood to the body.
“We found that reaching remission was common and that nearly [half] of patients who reached remission experienced a clinical relapse across extended follow-up,” the researchers wrote.
Greater the damage seen on early MRI scans, greater the risk of relapse
A battery of statistical tests then looked for factors associated with relapse risk. Researchers found no association between relapse risk and demographic factors like age, sex, and race. There also was no link based on different types of anti-inflammatory treatments used.
However, findings suggested that an MRI of the heart could help to identify relapse risk. MRI, or magnetic resonance imaging, is a technology that uses powerful magnets to visualize structures inside the body.
Specifically, the team found that late gadolinium enhancement (LGE) — where a dye injected into the bloodstream causes certain tissues to “light up” on MRI scans — could predict the risk of relapse. In statistical models, patients who had an LGE of 11% or higher before treatment were roughly five times more likely to experience a relapse, compared with those with less LGE. Patients with more LGE also tended to relapse more quickly.
“We identified greater disease burden on cardiac MRI, quantified by LGE percentage, as the strongest predictor of relapse risk and shorter time to relapse,” the researchers wrote.
Results also showed that patients with isolated cardiac sarcoidosis — that is, sarcoidosis in the heart but not in other organs or tissues — tended to have a shorter time to relapse than those with sarcoidosis affecting other body areas.
The researchers noted that it’s not clear whether this is due to differences in the underlying disease, or differences in how patients are managed in clinics. They highlighted a need for further study.
This work is limited by its use of data from patients at only one center, and by an inability to fully account for ways in which clinical care has evolved across the decades studied, the scientists also noted.
They emphasized a need for more studies to better understand the risk of relapse in cardiac sarcoidosis, and to look into strategies to optimally monitor and treat patients to reduce the risk of serious problems due to relapses.
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