High Dose Intravenous Glucocorticoids are Effective in the Acute Management of Ventricular Arrhythmias in Cardiac Sarcoidosis: A Case Series

Sarcoidosis is an autoimmune disorder in which granulomatous inflammation leads to multiorgan dysfunction. Cardiac involvement in particular is associated with substantial morbidity and mortality.1 Potential cardiac manifestations include atrioventricular block, ventricular tachycardia (VT), heart failure, and sudden death. Steroids are recommended for pulmonary sarcoidosis and may be effective for cardiac involvement as well. For instance, steroid therapy is reported to be associated with improvement in atrioventricular block and left ventricular (LV) function.2,3 Based on this sort of observational data, the Heart Rhythm Society recommends immunosuppression for active cardiac sarcoidosis.4 Key Teaching Points • Cardiac sarcoidosis is a disease in which granulomatous inflammation in the heart leads to cardiac dysfunction. Cardiac sarcoidosis most commonly manifests with left ventricular dysfunction, heart block, and/or atrial or ventricular arrhythmias. • Ventricular tachycardia (VT) is a particularly devastating complication of cardiac sarcoidosis and is associated with increased morbidity and mortality. Despite optimal treatment, patients often have recurrence of VT and are at increased risk of sudden cardiac death. • VT in cardiac sarcoidosis may occur as a result of either inflammation or scar. Scar-mediated VT is generally caused by re-entry around sites of scar, whereas inflammatory VT is generally a result of increased automaticity. • VT in cardiac sarcoidosis may be treated with immunosuppression, antiarrhythmic drugs, or catheter ablation. Immunosuppression seems to be most useful for patients with automaticity-mediated VT secondary to inflammation. • In our case series, high-dose intravenous (IV) glucocorticoids were an effective treatment for malignant ventricular arrhythmias in cardiac sarcoidosis patients with active myocardial inflammation. The use of high-dose IV glucocorticoids has previously been validated in other systemic rheumatologic diseases, including rheumatoid arthritis, lupus, and organ transplant rejection.