cardio.cardiac-sarcoidosis.chronic.v1PRODUCTION

cardio.cardiac-sarcoidosis.chronic.v1

Cardiac sarcoidosis (chronic — immunosuppression + arrhythmic protection)

cardiologychronicadult

Hard-required inputs

0 / 8

Care setting:

Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Suspect CS — especially young adult with unexplained high-grade AV block or non-ischemic VT

Inputs

Actions

Advance rule

Set

Advance when

CS clinically suspected

Patient inputs (11)

cmr_lge_pattern*imaging • BRANCHING_WORKUP

not present

Patchy mid-wall/epicardial multi-territory LGE — CS imaging criterion

fdg_pet_activity*imaging • BRANCHING_WORKUP

not present

Active inflammation — directs + monitors immunosuppression

age*demographic • FRAME

Young unexplained AV block strongly suggests CS

av_block_grade*imaging • RED_FLAGS

not present

High-grade AV block — pacing + CS workup trigger

lvef*imaging • RISK_STRATIFICATION

not present

Systolic dysfunction → HFrEF GDMT + ICD criteria

sustained_va*history • RISK_STRATIFICATION

not present

Spontaneous sustained VT/VF = ICD (2014 HRS)

nyha_class*symptom • RISK_STRATIFICATION

Functional status + GDMT/transplant timing

creatinine*lab • TREATMENT

Immunosuppressant + GDMT dosing

extracardiac_sarcoidhistory • CONTEXT

not present

Biopsy-proven extracardiac sarcoid supports clinical CS diagnosis

atrial_fibrillationhistory • CONTEXT

not present

AF — rate/rhythm + anticoagulation

troponin_nt_probnplab • INITIAL_WORKUP

Myocardial injury/HF burden

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (9)

9 need judgement

informationallife_threateningsustained_va_icd
Spontaneous sustained VT/VF in CS — ICD (secondary prevention) — 2014 HRS
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateninggiant_cell_myocarditis_overlap
Fulminant, rapidly progressive course with VT/cardiogenic shock — consider giant-cell myocarditis (biopsy) — different urgent immunosuppression — 2014 HRS
Trigger could not be auto-evaluated — needs clinician judgement.
informationallife_threateningtransplant_branch
End-stage CS cardiomyopathy or intractable VT despite therapy — transplant evaluation (good outcomes; immunosuppression continues) — 2023 ESC Cardiomyopathy
Trigger could not be auto-evaluated — needs clinician judgement.
informationalsevereyoung_unexplained_av_block
Unexplained high-grade AV block in adult <60 — CS until proven otherwise; advanced imaging (MRI/PET) BEFORE committing to a pacemaker-only device — 2014 HRS
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverefdg_pet_active_immunosuppression
FDG-PET-active myocardial inflammation — corticosteroid immunosuppression to halt progression; titrate to serial PET — 2014 HRS
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseveresystolic_dysfunction_gdmt
CS with LVEF ≤40 — standard HFrEF 4-pillar GDMT applies (granulomatous, not amyloid-stiff) — 2022 ACC/AHA HF
Trigger could not be auto-evaluated — needs clinician judgement.
informationalseverepregnancy_special_pop
Pregnancy with CS — immunosuppressant selection (avoid methotrexate/mycophenolate; prednisone/azathioprine relatively safer), arrhythmia + device monitoring; cardio-obstetric — ESC 2018 Pregnancy
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderatesteroid_toxicity_branch
Steroid toxicity / inability to taper — add steroid-sparing (methotrexate/azathioprine) or biologic; monitor glucose/bone/BP — 2014 HRS
Trigger could not be auto-evaluated — needs clinician judgement.
informationalmoderateckd_special_pop
CKD — immunosuppressant + GDMT dose-gating; renal sarcoid co-involvement — KDIGO 2024
Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

TREATMENTrequiredDrives dose adjustment

Loading…

Recommended regimen

Cardiac sarcoidosis — FDG-PET-guided immunosuppression + arrhythmic protection (2014 HRS; 2023 ESC Cardiomyopathy)

axis: cs_immunosuppression_and_arrhythmic_protectionstep 1 - Step 1 — Confirm CS + assess inflammation activity (FDG-PET) and arrhythmic risk

Selected step "Step 1 — Confirm CS + assess inflammation activity (FDG-PET) and arrhythmic risk" — Suspected CS (AV block / VT / patchy LGE / systemic sarcoid)

outpatient playbook — drug actions (3)

1. prednisone for PET-active inflammation
30–40 mg/day then taper • PO • daily
trigger: FDG-PET-active CS (2014 HRS)
First-line immunosuppression
2. methotrexate/azathioprine steroid-sparing
MTX 10–15 mg weekly • PO • weekly/daily
trigger: Steroid taper / toxicity (2014 HRS)
Steroid-sparing
3. pacemaker/ICD + AAD; HFrEF GDMT if low EF
device / amiodarone / per HFrEF • device/PO • n/a
trigger: AV block / VA / LVEF ≤35 (2014 HRS)
Arrhythmic protection + HF therapy

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Unexplained high-grade AV block in adult <60 — CS until proven otherwise; Ventricular tachycardia / palpitations of unclear cause; CMR patchy non-ischemic LGE / FDG-PET focal myocardial uptake.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Cardiac sarcoidosis (chronic — immunosuppression + arrhythmic protection)** (cardio.cardiac-sarcoidosis.chronic.v1).
Phenotype framing: CS vs ARVC vs giant-cell myocarditis vs idiopathic VT/DCM vs amyloid
Scope: Suspect CS — especially young adult with unexplained high-grade AV block or non-ischemic VT

No severity triggers fired against current inputs.

Plan

Regimen axis: **Cardiac sarcoidosis — FDG-PET-guided immunosuppression + arrhythmic protection (2014 HRS; 2023 ESC Cardiomyopathy)** — step "Step 1 — Confirm CS + assess inflammation activity (FDG-PET) and arrhythmic risk".

Setting playbook (outpatient) — Confirm CS, FDG-PET-guide immunosuppression, protect against SCD/AV block (low ICD threshold), GDMT for systolic dysfunction (2014 HRS; 2023 ESC Cardiomyopathy)
1. prednisone for PET-active inflammation 30–40 mg/day then taper PO daily — FDG-PET-active CS (2014 HRS) (First-line immunosuppression)
2. methotrexate/azathioprine steroid-sparing MTX 10–15 mg weekly PO weekly/daily — Steroid taper / toxicity (2014 HRS) (Steroid-sparing)
3. pacemaker/ICD + AAD; HFrEF GDMT if low EF device / amiodarone / per HFrEF device/PO n/a — AV block / VA / LVEF ≤35 (2014 HRS) (Arrhythmic protection + HF therapy)

Non-pharmacologic actions:
- Cardiac-sarcoidosis centre + EP referral — 2014 HRS
- ICD-capable device when pacing indicated in CS — 2014 HRS
- Transplant evaluation for end-stage — 2023 ESC Cardiomyopathy

AVOID / contraindication checks:
- Young unexplained high grade AV block workup for CS before permanent pacing alone — 2014 HRS
- Use ICD capable device when pacing indicated in CS high VA risk — 2014 HRS
- Titrate immunosuppression to serial FDG PET activity — 2014 HRS
- Standard HFrEF GDMT applies in CS systolic dysfunction — 2022 ACC/AHA HF
- Consider giant cell myocarditis if fulminant rapidly progressive — 2014 HRS

Monitoring

Regimen monitoring:
- serial FDG PET to titrate immunosuppression — 2014 HRS
- device interrogation for AV block and VA — 2014 HRS
- serial LVEF and VA surveillance — 2014 HRS
- steroid toxicity surveillance glucose bone BP — 2014 HRS
- systemic sarcoid co management — 2023 ESC Cardiomyopathy

Setting (outpatient) monitoring:
- Serial FDG-PET to titrate immunosuppression — 2014 HRS
- Device + LVEF + VA surveillance; steroid toxicity — 2014 HRS

Follow-up plan: Steroid-sparing taper, relapse surveillance, systemic-sarcoid co-management
- Close-out criterion: long-term immunosuppression + relapse plan documented

Monitoring phase: Serial FDG-PET to titrate immunosuppression; device interrogation; LVEF/VA surveillance

Disposition

Current setting: outpatient — Confirm CS, FDG-PET-guide immunosuppression, protect against SCD/AV block (low ICD threshold), GDMT for systolic dysfunction (2014 HRS; 2023 ESC Cardiomyopathy)

Disposition criteria:
- PET-active → immunosuppression + device by risk + serial PET
- PET-inactive, low risk → surveillance ± maintenance steroid-sparing
- End-stage → transplant evaluation

Escalation triggers (move to higher acuity):
- Complete heart block / sustained VT → EP + ICD-capable device now — 2014 HRS
- Fulminant/rapidly progressive → consider giant-cell myocarditis, acute pathway — 2014 HRS
- End-stage cardiomyopathy / intractable VT → transplant — 2023 ESC Cardiomyopathy

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Spontaneous sustained VT/VF in CS — ICD (secondary prevention) — 2014 HRS
- [LIFE_THREATENING] Fulminant, rapidly progressive course with VT/cardiogenic shock — consider giant-cell myocarditis (biopsy) — different urgent immunosuppression — 2014 HRS
- [LIFE_THREATENING] End-stage CS cardiomyopathy or intractable VT despite therapy — transplant evaluation (good outcomes; immunosuppression continues) — 2023 ESC Cardiomyopathy

Citations

- 2014 HRS Cardiac Sarcoidosis Expert Consensus + 2023 ESC Cardiomyopathy Guideline + 2022 AHA/ACC/HFSA HF Guideline [PMID:24819193](https://pubmed.ncbi.nlm.nih.gov/24819193/)
- Cited evidence (PMID 37622657) [PMID:37622657](https://pubmed.ncbi.nlm.nih.gov/37622657/)
- Cited evidence (PMID 35379504) [PMID:35379504](https://pubmed.ncbi.nlm.nih.gov/35379504/)
- Cited evidence (PMID 37622666) [PMID:37622666](https://pubmed.ncbi.nlm.nih.gov/37622666/)
- Cited evidence (PMID 31535829) [PMID:31535829](https://pubmed.ncbi.nlm.nih.gov/31535829/)

Last reconciled with current guidelines: 2026-05-16.

References

2014 HRS Cardiac Sarcoidosis Expert Consensus + 2023 ESC Cardiomyopathy Guideline + 2022 AHA/ACC/HFSA HF Guideline — PMID:24819193
Cited evidence (PMID 37622657) — PMID:37622657
Cited evidence (PMID 35379504) — PMID:35379504
Cited evidence (PMID 37622666) — PMID:37622666
Cited evidence (PMID 31535829) — PMID:31535829