Cardiovascular magnetic resonance phenotyping in cardiac sarcoidosis: simplicity is indeed the ultimate sophistication for primary prevention implantable cardioverter-defibrillator decisions
Key result
CMR phenotyping outperformed all LGE extent-based approaches for predicting incident ventricular arrhythmias in patients with suspected cardiac sarcoidosis.
Why the study?
Does CMR phenotyping improve prediction of incident ventricular arrhythmias compared to LGE extent-based approaches in patients with suspected cardiac sarcoidosis?
Key Points
- Clarify and validate the superiority of cardiovascular magnetic resonance (CMR) phenotyping over quantitative late gadolinium enhancement (LGE) extent thresholds for guiding implantable cardioverter-defibrillator decisions in cardiac sarcoidosis.
- Evaluated CMR phenotyping against 2017 AHA/ACC/HRS and 2022 ESC societal guideline recommendations using multiple LGE extent thresholds (>0%, >5.7%, and ≥22%).
- Assessed independent predictive performance against LGE extent as a continuous variable in a cohort of 504 patients with suspected cardiac sarcoidosis.
- CMR phenotyping outperformed all tested quantitative LGE extent-based strategies and societal guideline recommendations.
- CMR phenotyping predicted incident ventricular arrhythmias independently of quantitative LGE extent measured as a continuous variable.
Structured PICO
Does CMR phenotyping improve prediction of incident ventricular arrhythmias compared to LGE extent-based approaches in patients with suspected cardiac sarcoidosis?
P
Population
504 patients with suspected cardiac sarcoidosis from a prior study evaluating CMR phenotyping.
E
Exposure
Cardiovascular magnetic resonance (CMR) phenotyping
C
Comparator
Late gadolinium enhancement (LGE) extent-based approaches (including 2017 AHA/ACC/HRS and 2022 ESC guidelines)
O
Outcome
Incident ventricular arrhythmiashard clinical
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“Our research has developed a simpler and better way to identify which patients with suspected cardiac sarcoidosis are most likely to benefit from an implantable cardioverter-defibrillator that can prevent sudden cardiac death. Our findings can be applied immediately in clinical practice to help patients at risk.”
“CMR phenotyping can be used immediately in clinical practice to identify patients with suspected cardiac sarcoidosis who would benefit from a primary prevention ICD.”
Implication
CMR phenotyping appears superior to simple LGE extent thresholds for predicting ventricular arrhythmias in suspected cardiac sarcoidosis, supporting its use for primary prevention ICD decisions.
Abstract
This commentary refers to ‘Prediction of ventricular arrhythmic outcomes in suspected cardiac sarcoidosis: a comparison of cardiovascular magnetic resonance phenotyping vs. societal recommendations for implantable cardioverter-defibrillator placement’, by H. Mathijssen et al., https://doi.org/10.1093/eurheartj/ehaf338 and the discussion piece ‘CMR Phenotyping in Sarcoidosis: A Leap Forward, But is Simplicity the Ultimate Sophistication?’, by J.-Y. Xiang et al., https://doi.org/10.1093/eurheartj/ehaf1025. We thank Xiang et al.1 for their interest in our study. They claim we did not ‘definitively prove the primacy of pattern over the principle of quantitative extent’ because we used a late gadolinium enhancement (LGE) extent threshold from our prior study2 rather than derive a new optimal threshold. This critique, however, confuses two distinct processes: validation and optimization. We tested LGE extent thresholds of any LGE (>0%) and >5.7% with the 2017 AHA/ACC/HRS guidelines, and >5.7% and ≥22% with the 2022 ESC guidelines. CMR phenotyping outperformed all LGE extent-based approaches. Moreover, in our prior study of 504 patients with suspected cardiac sarcoidosis, CMR phenotyping predicted incident ventricular arrhythmias independent of LGE extent as a continuous variable.3
Discussion
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Cite This Study
A 2025 study conducted a letter in suspected cardiac sarcoidosis (n=504). CMR phenotyping vs. LGE extent-based approaches was evaluated on incident ventricular arrhythmias. CMR phenotyping outperformed all LGE extent-based approaches for predicting incident ventricular arrhythmias in patients with suspected cardiac sarcoidosis.