Prevalence of atrial FDG uptake and association with atrial arrhythmias in patients with cardiac sarcoidosis

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Highlights

  • We found a high prevalence of atrial FDG uptake in patients with Cardiac Sarcoidosis.

  • A significant association between atrial arrhythmias and age, atrial FDG uptake, and left atrial diameter was demonstrated.

  • Gender, ACE and NT-proBNP levels, and LVEF were not associated with atrial arrhythmias.

Abstract

Background

There is increasing evidence that a proportion of patients with cardiac sarcoidosis (CS) have atrial arrhythmias (AA). Although 18F-fluorodeoxy-glucose (FDG) uptake in the ventricle on positron emission tomography/computed tomography (PET/CT) is well studied, FDG uptake in the atrium has not been elucidated in detail.

Objectives

To evaluate FDG uptake in the atrium and its relationship with AA in patients with CS.

Methods

We retrospectively investigated 62 CS patients. All patients underwent echocardiography and PET/CT. Serum angiotensin converting enzyme (ACE) and soluble IL-2 receptor (sIL-2R) levels, plasma N-terminal pro–brain natriuretic peptide (NT-proBNP) concentrations were also evaluated. ECG, Holter monitoring and device interrogations were used to detect AA.

Results

Of the studied population, 25 patients (40.3%) had AA, of which 2 patients had atrial tachycardia (AT) and 23 patients had atrial fibrillation (AF). Eighteen patients with AA had atrial FDG uptake on PET/CT, whereas 14 patients without AA had atrial FDG uptake (72.0% vs 37.8%, P = 0.017). Multivariate analysis revealed a significant association between AA and age (odds ratio [OR]: 1.15; 95% confidence interval [CI]: 1.01–1.31, P = 0.040), atrial FDG uptake (odds ratio [OR]: 7.23; 95% confidence interval [CI]: 1.91–27.36, P = 0.004), and left atrial diameter (OR: 1.08; 95% CI: 1.01–1.16, P = 0.027). Meanwhile, gender, serum ACE and BNP levels, and left ventricular ejection fraction were not associated with AA.

Conclusions

Atrial FDG uptake was common in patients with CS and strongly associated with AA.

Introduction

Sarcoidosis is a multisystemic granulomatous disease of unknown etiology characterized by the formation of noncaseating granulomas involving multiple organs [1]. Cardiac involvement is relatively rare but important as it is responsible for morbidity and mortality in patients with sarcoidosis [[2], [3], [4], [5]]. The main clinical manifestations of cardiac involvement are conduction abnormalities, heart failure, and ventricular arrhythmias [6]. Atrial arrhythmias (AA) had been reported to be less common than ventricular arrhythmias, with an incidence of 17% [4]. However, there is increasing evidence in recent years that a proportion of patients with cardiac sarcoidosis (CS) do in fact have AA [[7], [8], [9]].

Cardiac magnetic resonance imaging (CMR) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) are useful modalities to diagnose CS. Although delayed enhancement on CMR has high sensitivity for diagnosing CS [10], its specificity is relatively low because it can be detected in the other diseases such as ischemic heart disease and dilated cardiomyopathy. Meanwhile, PET has been reported to be useful for detecting CS with a sensitivity and specificity of 89% and 78%, respectively [11]. FDG uptake in the ventricle on positron emission tomography/computed tomography (PET/CT) is well studied, and focal FDG uptake is associated with poor prognosis [[11], [12], [13], [14]]. However, FDG uptake in the atrium has not been elucidated in detail. The present study seeks to evaluate FDG uptake in the atrium and its relationship with AA in patients with CS.

Section snippets

Study population

We retrospectively investigated consecutive 62 CS patients who underwent PET/CT from April 2006 to March 2018. The diagnosis of CS was made based on the Heart Rhythm Society (HRS) consensus criteria [15]. Thirty two patients had a cardiac device for arrhythmias (pacemaker, n = 21; implantable cardioverter defibrillator, n = 4; cardiac resynchronization therapy defibrillator, n = 7).

We conducted a medical record review to determine the prevalence of known AA, and its association with clinical

Results

Of the studied population, 25 patients (40.3%) had AA, of which 4 patients had atrial tachycardia (AT) and 23 patients had atrial fibrillation (AF). Two patients had both AT and AF. Nineteen out of 23 AFs (84%) were paroxysmal, while 4 AFs were persistent. Characteristics of the patients are summarized in Table 1. The majority of patients did not taking prednisolone because a series of examinations were conducted at the time of diagnosis. PET/CT demonstrated positive atrial uptake in 32

Discussion

The present study demonstrated high prevalence of AA in cardiac sarcoidosis, and its association to atrial FDG uptake, age, and left atrial diameter. Most of the patients with AA had AF (n = 23, 92.0%), including 2 patients who had both AT and AF. Meanwhile, the remaining 2 patients had only AT. All of the 4 AT patients had atrial FDG uptake, suggesting that atrial FDG uptake might be more associated with AT.

Viles-Gonzalez et al. investigated 100 patients with cardiac sarcoidosis and found that

Conclusions

Atrial FDG uptake was common in patients with CS and strongly associated with AA. FDG-PET may be useful for early detection of patients who are prone to developing AA. Close follow up should be considered in CS patients with atrial FDG uptake.

Funding sources

None.

CRediT authorship contribution statement

Kenji Yodogawa: Data curation, Writing - original draft. Yoshimitsu Fukushima: Conceptualization, Methodology, Software, Visualization, Investigation. Takahiro Ando: Software, Visualization, Investigation. Yu-ki Iwasaki: Writing - review & editing. Kazuyoshi Akiyama: Software, Visualization, Investigation. Shin-ichiro Kumita: Validation, Supervision. Arata Azuma: Writing - review & editing, Supervision. Yoshihiko Seino: Writing - review & editing, Supervision. Wataru Shimizu: Validation,

Declaration of competing interest

All authors have no relationships to disclose.

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