Effect of corticosteroid on arrhythmic events in patients with cardiac sarcoidosis
2013; Elsevier BV; Volume: 62; Issue: 5 Linguagem: Inglês
10.1016/j.jjcc.2013.09.004
ISSN1876-4738
Autores Tópico(s)Vasculitis and related conditions
ResumoSarcoidosis is a multisystem noncaseating granulomatous disease of unknown etiology. Pathologically, this granulomatous inflammation is characterized by accumulation of monocytes, macrophages, and activated T-lymphocytes, and there is evidence for a predominant type 1 T-helper cell response, resulting in an imbalance involving type 1 and type 2 helper-T cell cytokines and accelerated inflammation in sarcoidosis. It is most commonly observed in the lungs, but other organ systems (lymph nodes, skin, eyes, heart, nerves, and renal and endocrine systems) are also involved. Among them, cardiac sarcoidosis (CS) occurs in 20–27% of sarcoidosis patients in the USA and may occur more frequently in as many as 58% of patients in Japan [1Matsui Y. Iwai K. Tachibana T. Fruie T. Shigematsu N. Izumi T. Homma A.H. Mikami R. Hongo O. Hiraga Y. Yamamoto M. Clinicopathological study of fatal myocardial sarcoidosis.Ann N Y Acad Sci. 1976; 278: 455-469Crossref PubMed Scopus (312) Google Scholar, 2Roberts W.C. McAllister Jr., H.A. Ferrans V.J. Sarcoidosis of the heart. A clinicopathologic study of 35 necropsy patients (group 1) and review of 78 previously described necropsy patients (group 11).Am J Med. 1977; 63: 86-108Abstract Full Text PDF PubMed Scopus (644) Google Scholar, 3Silverman K.J. Hutchins G.M. Bulkley B.H. Cardiac sarcoid: a clinicopathologic study of 84 unselected patients with systemic sarcoidosis.Circulation. 1978; 58: 1204-1211Crossref PubMed Scopus (764) Google Scholar] and has a poor outcome because of congestive heart failure, atrioventricular (AV) block, and ventricular tachyarrhythmias (VT). Therapy with corticosteroids or other immunosuppressant agents has been reported to be effective to prevent progression of these cardiac conditions and improve survival in patients with CS [[4]Yazaki Y. Isobe M. Hiroe M. Morimoto S. Hiramitsu S. Nakano T. Izumi T. Sekiguchi M. Central Japan Heart Study G. Prognostic determinants of long-term survival in japanese patients with cardiac sarcoidosis treated with prednisone.Am J Cardiol. 2001; 88: 1006-1010Abstract Full Text Full Text PDF PubMed Scopus (505) Google Scholar]. The mechanism of action of corticosteroids in CS is unknown, but it is thought that corticosteroids could relieve the progression of inflammation and fibrosis through re-establishing a normal balance between locally produced type 1 and type 2 helper-T cell cytokines [[5]Newman L.S. Rose C.S. Maier L.A. Sarcoidosis.N Engl J Med. 1997; 336: 1224-1234Crossref PubMed Scopus (1398) Google Scholar], and thus early initiation of corticosteroids is recommended in CS patients. AV block is the most common arrhythmia in CS and is reported in 26–67% of patients [[6]Kim J.S. Judson M.A. Donnino R. Gold M. Cooper Jr., L.T. Prystowsky E.N. Prystowsky S. Cardiac sarcoidosis.Am Heart J. 2009; 157: 9-21Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar] due to involvement of the basal septum by a scar tissue or granulomas or the involvement of the nodal artery causing ischemia in the conduction system. Corticosteroids have been reported to be considered effective for the recovery of this AV block but not VT events in some CS patients (most of them were published from Japan) [7Banba K. Kusano K.F. Nakamura K. Morita H. Ogawa A. Ohtsuka F. Ogo K.O. Nishii N. Watanabe A. Nagase S. Sakuragi S. Ohe T. Relationship between arrhythmogenesis and disease activity in cardiac sarcoidosis.Heart Rhythm. 2007; 4: 1292-1299Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 8Kato Y. Morimoto S. Uemura A. Hiramitsu S. Ito T. Hishida H. Efficacy of corticosteroids in sarcoidosis presenting with atrioventricular block.Sarcoidosis Vasc Diffuse Lung Dis. 2003; 20: 133-137PubMed Google Scholar, 9Yodogawa K. Seino Y. Ohara T. Takayama H. Katoh T. Mizuno K. Effect of corticosteroid therapy on ventricular arrhythmias in patients with cardiac sarcoidosis.Ann Noninvasive Electrocardiol. 2011; 16: 140-147Crossref PubMed Scopus (133) Google Scholar]. Kato et al. reported that recovery of AV conduction was observed in 4 of 7 treated patients (57.1%) and all 13 untreated patients had persistent complete AV block after 79.4 months [[8]Kato Y. Morimoto S. Uemura A. Hiramitsu S. Ito T. Hishida H. Efficacy of corticosteroids in sarcoidosis presenting with atrioventricular block.Sarcoidosis Vasc Diffuse Lung Dis. 2003; 20: 133-137PubMed Google Scholar]. Banba et al. also reported that recovery of AV conduction was observed in 5 of 9 treated patients (56.6%), in whom AV conduction improved to normal in 3 patients and to transient first-degree AV block in 2 patients after a relatively short period of 6 months [[7]Banba K. Kusano K.F. Nakamura K. Morita H. Ogawa A. Ohtsuka F. Ogo K.O. Nishii N. Watanabe A. Nagase S. Sakuragi S. Ohe T. Relationship between arrhythmogenesis and disease activity in cardiac sarcoidosis.Heart Rhythm. 2007; 4: 1292-1299Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar]. In the recent systematic analysis review [[10]Sadek M.M. Yung D. Birnie D.H. Beanlands R.S. Nery P.B. Corticosteroid therapy for cardiac sarcoidosis: a systematic review.Can J Cardiol. 2013; 29: 1034-1041Abstract Full Text Full Text PDF PubMed Scopus (170) Google Scholar], 27 of 57 treated patients (47.4%) with AV block recovered AV conduction but none of the untreated patients improved. However, adequate dosage and long-term efficacy of corticosteroids on AV conduction system have not been proven to date. The results of the study by Yodogawa [[11]Yodogawa K. Recovery of atrioventricualr block following steroid therapy in patients with cardiac sarcoidosis.J Cardiol. 2013; 62: 320-325Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] published in this journal have indicated the interesting possibility that corticosteroid therapy is effective not only for the recovery of AV conduction, but also to maintain AV conduction. They reported that 7 of 15 CS patients (46.7%) with complete AV block recovered to normal conduction or first-degree AV conduction after corticosteroids (acute dose of 30 mg/day and maintenance dose of 5–10 mg/day) and this effect was sustained at least during a mean follow-up period of 7.1 years. They also reported that the recovery group had a higher left ventricular ejection fraction (69.4% vs. 44.1%) and a higher prevalence of advanced AV block (87.5% vs. 28.6%), indicating that early initiation of corticosteroids should be recommended in CS. Similar results were also reported by Banba et al. that positive Gallium-67 uptake was correlated with new onset of high-grade AV block but not VT episodes (80% in AV block vs. 14% in VT, p < 0.02) [[7]Banba K. Kusano K.F. Nakamura K. Morita H. Ogawa A. Ohtsuka F. Ogo K.O. Nishii N. Watanabe A. Nagase S. Sakuragi S. Ohe T. Relationship between arrhythmogenesis and disease activity in cardiac sarcoidosis.Heart Rhythm. 2007; 4: 1292-1299Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar]. These retrospective data indicates that AV block in CS develops mainly during the early, active, and inflammatory phase of the disease, and there is relatively higher possibility of AV conduction recovery after corticosteroid therapy. However, in view of the unpredictable response, all patients diagnosed with CS should receive pacemaker implantation. Unlike in the case of AV block, the effect of corticosteroids on VT was not consistent in the previous reports. A favorable effect was reported by Futamatsu et al. [[12]Futamatsu H. Suzuki J. Adachi S. Okada H. Otomo K. Ohara T. Hashimoto Y. Kakuta T. Iesaka Y. Yamaguchi H. Sakurada H. Sato A. Obayashi T. Niwa A. Hirao K. et al.Utility of gallium-67 scintigraphy for evaluation of cardiac sarcoidosis with ventricular tachycardia.Int J Cardiovasc Imaging. 2006; 22: 443-448Crossref PubMed Scopus (55) Google Scholar] and Yodogawa et al. (the patients were included in this study) [[9]Yodogawa K. Seino Y. Ohara T. Takayama H. Katoh T. Mizuno K. Effect of corticosteroid therapy on ventricular arrhythmias in patients with cardiac sarcoidosis.Ann Noninvasive Electrocardiol. 2011; 16: 140-147Crossref PubMed Scopus (133) Google Scholar], but amiodarone was started concomitantly in the former report and only the reduction of ventricular premature contractions and nonsustained VT in the subgroup of patients with left ventricular ejection fraction >35% in the latter group. Because it appears likely that in many cases VT is related to scar formation, corticosteroids might have little beneficial effect on VT events. Thus, CS patients with VT should receive an implantable cardioverter defibrillator. In conclusion, although the number of patients in this study was small and a further prospective registry or randomized study is needed to reach a definitive conclusion, Yodogawa et al. have provided important clinical evidence suggesting that early initiation of corticosteroid therapy is effective for the recovery of AV block in CS patients and may be a possible therapeutic strategy for some selected CS patients. Recovery of atrioventricular block following steroid therapy in patients with cardiac sarcoidosisJournal of CardiologyVol. 62Issue 5PreviewAtrioventricular (AV) block is one of the main clinical manifestations in patients with cardiac sarcoidosis (CS). Although steroid therapy is considered to be effective for AV block, the efficacy has not been demonstrated in detail. Full-Text PDF Open Archive
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