Top 7 Diagnostic Dilemmas in Cardiac Sarcoidosis: Lessons from Clinical Practice

Cardiac sarcoidosis (CS) is a potentially fatal but often underrecognized manifestation of systemic sarcoidosis. Its diagnosis remains a major clinical challenge due to nonspecific symptoms, overlapping features with other cardiac and genetic diseases, and the lack of a universal diagnostic gold standard. This review outlines seven key diagnostic dilemmas frequently encountered in clinical practice: (1) failure to consider CS, (2) premature attribution of findings to CS, (3) limitations and misinterpretation of echocardiogram and cardiac magnetic resonance imaging, (4) limitations of ¹⁸F-FDG positron emission tomography, (5) mistaking mutation for granuloma, (6) biopsy paradox, and (7) navigating diagnostic definitions. Each dilemma highlights the need for careful clinical reasoning, multimodal imaging interpretation, integration of data, and expert multidisciplinary collaboration. Ultimately, a nuanced, patient-centered, and evidence-informed approach is essential to improve diagnosis and outcomes in patients with suspected CS.