In their report on cardiac sarcoidosis, Smedema et al (July 2005)1remarkably conclude that patients without cardiac symptoms do not require more sensitive studies to detect heart disease. This report, while of interest, is limited by a patient follow-up that varied widely from 3 to 54 months. Since this study does not well characterize the natural history of asymptomatic cardiac sarcoidosis and, as related in the accompanying editorial by Judson,2 sudden death is a tragic occurrence in seemingly healthy young patients, the conclusions of Smedema et al1 are not reassuring. The authors list “heart failure” as the symptom of cardiac involvement in 14 of their 19 patients, and only 7 patients are listed as having “probable arrhythmias.” Thus, it appears that the cause of morbidity and mortality from cardiac sarcoidosis has shifted from death due to fatal malignant arrhythmias to death due to progressive loss of left ventricular function. Presumably, the loss of ventricular function and arrhythmias are due to granulomatous inflammation or myocardial scarring. We think that the early recognition of active myocardial sarcoidosis such as with MRI, as found in 12 of the 82 patients who were deemed not to have cardiac sarcoidosis, or utilizing other sensitive tests such as positron emission tomography scans might have alerted the physicians to the presence of treatable myocardial disease.