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Background Worse prognosis in cardiac sarcoidosis (CS) is likely associated with diagnostic delay and cardiac involvement as first sarcoidosis (de novo) presentation, but data are limited.Methods We retrospectively investigated 95 patients with CS diagnosed 2003–2024. Using electronic health records, the date of first CS symptoms/signs, immunosuppressant therapy and follow-up data including left ventricular ejection fraction (LVEF), biomarkers and cardiac device therapy were extracted. Median time from first symptoms/signs to CS diagnosis (9 months) was used to define delayed diagnosis.Results Implantation of cardiac resynchronisation therapy defibrillator was more likely in patients with diagnostic delay (p=0.01). No difference was observed in time to diagnosis between patients with de novo CS (n=49) and those with prior extracardiac sarcoidosis (ECS) (n=46). Severe symptoms at disease onset were more common in de novo CS. At a median of 46 months from diagnosis, de novo patients more often had reduced LVEF (p=0.006) and an implantable cardioverter defibrillator (p<0.05) than those with prior ECS despite receiving more immunosuppressant therapy. De novo patients with diagnostic delay more often had reduced LVEF at CS presentation.Conclusions Symptom presentation is likely associated with diagnostic delay, but the disease presentation and course seem more severe in de novo CS and may not be altered by immunosuppressants, or demand more aggressive therapy.