Development of Imaging Endpoints for Clinical Trials in AL & ATTR Amyloidosis: Amyloidosis Forum Proceedings-Article: Global Practices in Cardiac Imaging for Cardiac Sarcoidosis: Delphi Consensus Survey Study of International Experts

Article: Global Practices in Cardiac Imaging for Cardiac Sarcoidosis: Delphi Consensus Survey Study of International Experts

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This international Delphi consensus study gathered 89 multidisciplinary cardiac sarcoidosis (CS) experts from 61 centers across 13 countries to assess global practices in cardiac imaging for suspected and established CS. The goal was to identify consensus areas and highlight topics needing further research due to considerable variability in clinical approaches worldwide.<br /><br />Key findings include a low threshold among experts to order advanced cardiac imaging—cardiac magnetic resonance (CMR) and 18F-fluorodeoxyglucose positron emission tomography (FDG-PET)—when new rhythm abnormalities or ventricular dysfunction arise in patients with extracardiac sarcoidosis. FDG-PET and CMR were agreed upon as complementary imaging modalities for initial CS diagnosis. If CMR is used first, FDG-PET is recommended following any abnormal CMR or even after a normal CMR if pretest probability is moderate or high.<br /><br />Late gadolinium enhancement (LGE) on CMR is recognized as a significant risk factor for adverse cardiac events, yet there is no consensus on optimal quantification methods or risk thresholds for LGE burden. Similarly, reduction in FDG uptake guides treatment response, but consensus lacks on quantification methods, defining adequate radiographic response, or whether complete FDG resolution should be the treatment goal.<br /><br />In follow-up imaging, intervals for repeat FDG-PET vary widely and are generally guided by clinical response to immunosuppression. Annual indefinite FDG-PET imaging in stable patients was not supported. Monitoring of clinically silent CS remains controversial, with no agreement on necessity or approach.<br /><br />The study identified significant heterogeneity in imaging accessibility, especially outside the United States, and variable use of advanced imaging thresholds and follow-up timing. It highlighted the need for multidisciplinary teams in CS management and underscored numerous research gaps, including standardizing LGE and FDG-PET quantification, defining treatment response criteria, and optimizing imaging follow-up schedules.<br /><br />In conclusion, while consensus exists regarding certain imaging indications and complementary use of CMR and FDG-PET, many decision points lack uniform agreement, reflecting limited prospective data. This study provides practical expert guidance and identifies priorities for future multinational, controlled research to refine cardiac imaging approaches in sarcoidosis.

Keywords

cardiac sarcoidosis

Delphi consensus

cardiac imaging

cardiac magnetic resonance

FDG-PET

late gadolinium enhancement

imaging follow-up

immunosuppression monitoring

multidisciplinary management

research gaps