Objectives We sought to relate imaging findings on PET to adverse cardiac events in patients referred for evaluation of known or suspected cardiac sarcoidosis (CS). Background Although cardiac positron emission tomography (PET) is commonly used to evaluate patients with suspected CS, the relationship between PET findings and clinical outcomes has not been reported. Methods We studied 118 consecutive patients with no history of CAD who were referred for PET using 18F-fluorodeoxyglucose (FDG) [to assess for inflammation] and 82Rubidium [to evaluate for perfusion defects (PD)] following a high fat / low carbohydrate diet to suppress normal myocardial glucose uptake. Blind reads of the PET data categorized cardiac findings as (a) normal; (b) positive PD or FDG; (c) positive PD and FDG. Images were also used to identify if findings for extra cardiac sarcoidosis were present. Adverse events (AE) -- death or sustained ventricular tachycardia (VT) -- were ascertained by electronic medical records, defibrillator interrogation, patient questionnaires and phone interviews. Results Among the 118 patients (age 52±11; males 57%, mean ejection fraction 47%±16%), 47 (40%) had normal and 71 (60%) abnormal cardiac PET findings. Over a median follow-up of 1.5 years, there were 31 (26%) adverse events (27 VT and 8 deaths). Cardiac PET findings were predictive of AE with the presence of both a PD and abnormal FDG (29% of patients) being associated with hazard ratio of 3.9 (p<0.01) and remaining significant after adjusting for left ventricular ejection fraction (LVEF) and clinical criteria. Extra-cardiac FDG uptake (26% of patients) was not associated with AE. Conclusions The presence of focal PD and FDG uptake on cardiac PET identifies patients at higher risk of death or VT. These findings offer prognostic value beyond Japanese clinical criteria, the presence of extra cardiac sarcoidosis and LVEF.

Hulsmans et al. show that cardiac macrophages expand in left ventricular diastolic dysfunction, a hallmark of heart failure with preserved ejection fraction (HFpEF) and cardiac aging. In HFpEF, macrophages shift toward a profibrotic subset that promotes ventricular stiffness.

In symptomatic patients without overt CAD, impaired CFR was independently associated with diastolic dysfunction and adverse events, especially HFpEF hospitalization. The presence of both coronary microvascular and diastolic dysfunctions was associated with a markedly increased risk of HFpEF events.