This study examines the incidence and clinical significance of cardiac sarcoidosis in 84 consecutive autopsied patients with systemic sarcoidosis. The patients ranged in age from 18 to 80 years, with an average age of 46 years, and 61% were women. Of the 84 patients, 23 (27%) had myocardial granulomas, with only four (17%) showing grossly evident widespread myocardial involvement. In these four patients, all had sudden, unexpected death at an average age of 36 years. The remaining 19 patients had microscopically evident granulomatous involvement, with eight (42%) experiencing rhythm or conduction disturbances and three (16%) sudden death. However, none of those who died suddenly had recognized rhythm or conduction disturbances. The study suggests that while myocardial involvement occurs in at least 25% of patients with sarcoidosis, it is often clinically silent and involves only a small portion of the myocardium. Rhythm and conduction disturbances are more common in patients with cardiac sarcoidosis, but only those with severe, grossly evident myocardial sarcoidosis are at increased risk for sudden death. The findings highlight the need for further research to identify and manage patients at risk for sudden death due to severe cardiac sarcoidosis.This study examines the incidence and clinical significance of cardiac sarcoidosis in 84 consecutive autopsied patients with systemic sarcoidosis. The patients ranged in age from 18 to 80 years, with an average age of 46 years, and 61% were women. Of the 84 patients, 23 (27%) had myocardial granulomas, with only four (17%) showing grossly evident widespread myocardial involvement. In these four patients, all had sudden, unexpected death at an average age of 36 years. The remaining 19 patients had microscopically evident granulomatous involvement, with eight (42%) experiencing rhythm or conduction disturbances and three (16%) sudden death. However, none of those who died suddenly had recognized rhythm or conduction disturbances. The study suggests that while myocardial involvement occurs in at least 25% of patients with sarcoidosis, it is often clinically silent and involves only a small portion of the myocardium. Rhythm and conduction disturbances are more common in patients with cardiac sarcoidosis, but only those with severe, grossly evident myocardial sarcoidosis are at increased risk for sudden death. The findings highlight the need for further research to identify and manage patients at risk for sudden death due to severe cardiac sarcoidosis.