Accepted Manuscript Letter by Eguchi et al. Regarding the Article Entitled, “Cardiac Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis” Kazuo Eguchi, MD, PhD Michiaki Hiroe, MD, PhD Kazuomi Kario, MD, PhD PII:
S0735-1097(14)01811-7
DOI:
10.1016/j.jacc.2014.01.076
Reference:
JAC 20041
To appear in:
Journal of the American College of Cardiology
Received Date: 2 January 2014 Accepted Date: 6 January 2014
Please cite this article as: Eguchi K, Hiroe M, Kario K, Letter by Eguchi et al. Regarding the Article Entitled, “Cardiac Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis”, Journal of the American College of Cardiology (2014), doi: 10.1016/ j.jacc.2014.01.076. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Letter by Eguchi et al. Regarding the Article Entitled, “Cardiac Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis” Kazuo Eguchi, MD, PhD1; Michiaki Hiroe, MD, PhD 1,2; Kazuomi Kario, MD, PhD1 1
2
RI PT
Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Japan Cardiology Division, National Center for Global Health and Medicine, Tokyo, Japan
M AN U
AC C
EP
TE D
Corresponding Author: Kazuo Eguchi Jichi Medical University Cardiovascular Medicine 3311-1 Yakushiji Shimotsuke, Tochigi-ken 329-0498 Japan +81285587344 +81285445317 (fax) [email protected]
SC
Disclosures: None
1
ACCEPTED MANUSCRIPT Cardiac positron emission tomography (PET) is now one of the most important diagnostic tools for the assessment of cardiac sarcoidosis (CS). The diagnostic accuracy of PET has been
RI PT
reported to show 100% sensitivity and 80%–90% specificity (1, 2). In this issue of the Journal of American College of Cardiology, Dr. Blankstein et al. clearly demonstrated that the presence of focal perfusion defect (PD) and FDG uptake on cardiac PET identified
SC
patients at higher risk of death or ventricular tachycardia (VT) (3). The focal FDG uptake in
M AN U
the right ventricle was also a very specific finding of CS. In their paper, although the results are very interesting, there are several problems to be acknowledged. The first is the lack of the evaluation of treatment before and after the diagnosis of CS. With effective anti-inflammatory treatment, the FDG uptake on PET will be diminished, but
TE D
if the extent of inflammation is advanced, only a partial effect can be obtained. The relationship between PET and treatment should thus be clarified.
EP
The second is the issue of the Japanese Ministry of Health and Welfare guidelines.
AC C
Reference #6 is not appropriate as a reference for these guidelines; it is simply a small clinical study of cardiac MRI. The quoted guideline is an older version of the guideline in reference (4) which was revised in 2006, and the clinical diagnosis group was newly set as a diagnostic criterion (5). It would therefore be interesting to compare both clinical and histological diagnoses using the 2006 Japanese guidelines. Third, regarding the baseline characteristics of the patients (Table 1), 90% of the 2
ACCEPTED MANUSCRIPT patients with adverse events had an implantable cardioverter defibrillator (ICD) at baseline or upon follow-up. Of 31 outcomes, there were 28 VT events. The reasons for the ICD
RI PT
implantations at baseline should be described, because VT events tend to occur in patients with ICDs.
Fourth, the fasting time “3 hours” is apparently insufficient to inhibit physiological
SC
uptake in non-affected myocardium, because we have recently reported that long fasting time
M AN U
more than 18hrs is necessary for the precise evaluation of cardiac PET (Morooka M, Moroi, M Uno K et al. Long fasting is effective in inhibiting physiological myocardial
18F-
FDG
uptake and for evaluating active lesions of cardiac sarcoidosis. Eur J Nucl Med and Mole Imaging (in press).)
TE D
Endomyocardial biopsy (EMBx) is usually performed, because the diagnosis of CS is based principally on histology. However, the diagnostic rate achieved with EMBx has been reported
EP
to be 20%–30% (7). In the Blankstein et al. study, very interesting findings about EMBx from
AC C
the right ventricle are reported. The overall diagnostic rate was 27%, but among the 20 patients with abnormal perfusion and FDG uptake, 45% were positive. These results indicate that a positive PET finding is useful not only for predicting outcomes, but also for determining the indications for performing an EMBx. Further study is needed to resolve the issue of whether a positive PET finding of myocardium can improve the diagnostic rate of EMBx. 3
ACCEPTED MANUSCRIPT
References 1.
Ishimaru S, Tsujino I, Takei T, Tsukamoto E, Sakaue S, Kamigaki M, et al. Focal
RI PT
uptake on 18F-fluoro-2-deoxyglucose positron emission tomography images indicates cardiac involvement of sarcoidosis. European Heart Journal. 2005 August 1, 2005;26(15):1538-43. 2.
Yamagishi H, Shirai N, Takagi M, Yoshiyama M, Akioka K, Takeuchi K, et al.
SC
Identification of Cardiac Sarcoidosis with 13N-NH3/18F-FDG PET. Journal of Nuclear
3.
M AN U
Medicine. 2003 July 1, 2003;44(7):1030-6.
Blankstein R, Osborne M, Naya M, Waller A, Kim CK, Murthy VL, et al. Cardiac
Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis. Journal of the American College of Cardiology. 2013(0). Hiraga H, Hiroe M, Iwai K et al. Guidelines for diagnosis of cardiac sarcoidosis:
TE D
4.
study report on diffuse pulmonary diseases (in Japanese). Tokyo: The Japanese Ministry of
Soejima K, Yada H. The Work-Up and Management of Patients with Apparent or
AC C
5.
EP
Health and Welfare. 1993(23-24).
Subclinical Cardiac Sarcoidosis: With Emphasis on the Associated Heart Rhythm Abnormalities. J Cardiovasc Electrophysiol. 2009;20(5):578-83. 6.
Langah R, Spicer K, Gebregziabher M, Gordon L. Effectiveness of prolonged
fasting 18f-FDG PET-CT in the detection of cardiac sarcoidosis. J Nucl Cardiol. 2009 2009/10/01;16(5):801-10. 4
ACCEPTED MANUSCRIPT 7.
Uemura A, Morimoto S, Hiramitsu S, Kato Y, Ito T, Hishida H. Histologic diagnostic
rate of cardiac sarcoidosis: evaluation of endomyocardial biopsies. Am Heart J. 1999;138((2
AC C
EP
TE D
M AN U
SC
RI PT
Pt 1):):299-302.
5
S0735-1097(14)01811-7
DOI:
10.1016/j.jacc.2014.01.076
Reference:
JAC 20041
To appear in:
Journal of the American College of Cardiology
Received Date: 2 January 2014 Accepted Date: 6 January 2014
Please cite this article as: Eguchi K, Hiroe M, Kario K, Letter by Eguchi et al. Regarding the Article Entitled, “Cardiac Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis”, Journal of the American College of Cardiology (2014), doi: 10.1016/ j.jacc.2014.01.076. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Letter by Eguchi et al. Regarding the Article Entitled, “Cardiac Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis” Kazuo Eguchi, MD, PhD1; Michiaki Hiroe, MD, PhD 1,2; Kazuomi Kario, MD, PhD1 1
2
RI PT
Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University, Shimotsuke, Japan Cardiology Division, National Center for Global Health and Medicine, Tokyo, Japan
M AN U
AC C
EP
TE D
Corresponding Author: Kazuo Eguchi Jichi Medical University Cardiovascular Medicine 3311-1 Yakushiji Shimotsuke, Tochigi-ken 329-0498 Japan +81285587344 +81285445317 (fax) [email protected]
SC
Disclosures: None
1
ACCEPTED MANUSCRIPT Cardiac positron emission tomography (PET) is now one of the most important diagnostic tools for the assessment of cardiac sarcoidosis (CS). The diagnostic accuracy of PET has been
RI PT
reported to show 100% sensitivity and 80%–90% specificity (1, 2). In this issue of the Journal of American College of Cardiology, Dr. Blankstein et al. clearly demonstrated that the presence of focal perfusion defect (PD) and FDG uptake on cardiac PET identified
SC
patients at higher risk of death or ventricular tachycardia (VT) (3). The focal FDG uptake in
M AN U
the right ventricle was also a very specific finding of CS. In their paper, although the results are very interesting, there are several problems to be acknowledged. The first is the lack of the evaluation of treatment before and after the diagnosis of CS. With effective anti-inflammatory treatment, the FDG uptake on PET will be diminished, but
TE D
if the extent of inflammation is advanced, only a partial effect can be obtained. The relationship between PET and treatment should thus be clarified.
EP
The second is the issue of the Japanese Ministry of Health and Welfare guidelines.
AC C
Reference #6 is not appropriate as a reference for these guidelines; it is simply a small clinical study of cardiac MRI. The quoted guideline is an older version of the guideline in reference (4) which was revised in 2006, and the clinical diagnosis group was newly set as a diagnostic criterion (5). It would therefore be interesting to compare both clinical and histological diagnoses using the 2006 Japanese guidelines. Third, regarding the baseline characteristics of the patients (Table 1), 90% of the 2
ACCEPTED MANUSCRIPT patients with adverse events had an implantable cardioverter defibrillator (ICD) at baseline or upon follow-up. Of 31 outcomes, there were 28 VT events. The reasons for the ICD
RI PT
implantations at baseline should be described, because VT events tend to occur in patients with ICDs.
Fourth, the fasting time “3 hours” is apparently insufficient to inhibit physiological
SC
uptake in non-affected myocardium, because we have recently reported that long fasting time
M AN U
more than 18hrs is necessary for the precise evaluation of cardiac PET (Morooka M, Moroi, M Uno K et al. Long fasting is effective in inhibiting physiological myocardial
18F-
FDG
uptake and for evaluating active lesions of cardiac sarcoidosis. Eur J Nucl Med and Mole Imaging (in press).)
TE D
Endomyocardial biopsy (EMBx) is usually performed, because the diagnosis of CS is based principally on histology. However, the diagnostic rate achieved with EMBx has been reported
EP
to be 20%–30% (7). In the Blankstein et al. study, very interesting findings about EMBx from
AC C
the right ventricle are reported. The overall diagnostic rate was 27%, but among the 20 patients with abnormal perfusion and FDG uptake, 45% were positive. These results indicate that a positive PET finding is useful not only for predicting outcomes, but also for determining the indications for performing an EMBx. Further study is needed to resolve the issue of whether a positive PET finding of myocardium can improve the diagnostic rate of EMBx. 3
ACCEPTED MANUSCRIPT
References 1.
Ishimaru S, Tsujino I, Takei T, Tsukamoto E, Sakaue S, Kamigaki M, et al. Focal
RI PT
uptake on 18F-fluoro-2-deoxyglucose positron emission tomography images indicates cardiac involvement of sarcoidosis. European Heart Journal. 2005 August 1, 2005;26(15):1538-43. 2.
Yamagishi H, Shirai N, Takagi M, Yoshiyama M, Akioka K, Takeuchi K, et al.
SC
Identification of Cardiac Sarcoidosis with 13N-NH3/18F-FDG PET. Journal of Nuclear
3.
M AN U
Medicine. 2003 July 1, 2003;44(7):1030-6.
Blankstein R, Osborne M, Naya M, Waller A, Kim CK, Murthy VL, et al. Cardiac
Positron Emission Tomography Enhances Prognostic Assessments of Patients with Suspected Cardiac Sarcoidosis. Journal of the American College of Cardiology. 2013(0). Hiraga H, Hiroe M, Iwai K et al. Guidelines for diagnosis of cardiac sarcoidosis:
TE D
4.
study report on diffuse pulmonary diseases (in Japanese). Tokyo: The Japanese Ministry of
Soejima K, Yada H. The Work-Up and Management of Patients with Apparent or
AC C
5.
EP
Health and Welfare. 1993(23-24).
Subclinical Cardiac Sarcoidosis: With Emphasis on the Associated Heart Rhythm Abnormalities. J Cardiovasc Electrophysiol. 2009;20(5):578-83. 6.
Langah R, Spicer K, Gebregziabher M, Gordon L. Effectiveness of prolonged
fasting 18f-FDG PET-CT in the detection of cardiac sarcoidosis. J Nucl Cardiol. 2009 2009/10/01;16(5):801-10. 4
ACCEPTED MANUSCRIPT 7.
Uemura A, Morimoto S, Hiramitsu S, Kato Y, Ito T, Hishida H. Histologic diagnostic
rate of cardiac sarcoidosis: evaluation of endomyocardial biopsies. Am Heart J. 1999;138((2
AC C
EP
TE D
M AN U
SC
RI PT
Pt 1):):299-302.
5
