Preliminary Diagnosis: Pericarditis

I. What imaging technique is first-line for this diagnosis?

  • Transthoracic echocardiography

II. Describe the advantages and disadvantages of this technique for diagnosis of pericarditis.

Advantages
  • Does not use ionizing radiation

  • Can determine life-threatening consequences such as pericardial tamponade

  • Useful to diagnose myocarditis and ventricular dysfunction, which could change the management approach

Disadvantages
  • Not sensitive to detect pericardial thickening in acute pericarditis and may be interpreted as normal in the absence of pleural effusion

  • Poor chest windows due to body habitus or chest wall abnormalities leads to poor image acquisition and evaluation

  • Loculated pleural effusions may not be detected

III. What are the contraindications for the first-line imaging technique?

  • None

IV. What alternative imaging techniques are available?

  • CT with and without IV contrast

  • MRI with and without IV contrast

  • Plain-film radiographs

V. Describe the advantages and disadvantages of the alternative techniques for diagnosis of pericarditis.

CT with and without IV contrast
Advantages
  • Demonstrates pericardial effusion and thickening (>4-6 mm)

  • Evaluating the density of the pericardial effusion can aide in diagnosis

  • Pericardial enhancement suggests active inflammation

  • Evaluates the entire pericardium

Disadvantages
  • Exposure to ionizing radiation

  • Risk of contrast-inducted nephropathy

  • Can not differentiate if pericardial thickening is constrictive or nonconstrictive

MRI with and without IV contrast
Advantages
  • Determines if an effusion is simple or complicated (hemorrhagic)

  • Pericardial enhancement suggests active inflammation

  • Highly sensitive to differentiate constrictive from restrictive cardiomyopathy

Disadvantages
  • Expensive

  • Time consuming

  • Requires significant patient cooperation to minimize motion artifact

  • Risk of nephrogenic systemic fibrosis in patient with poor renal function

Plain-film radiographs
Advantages
  • May demonstrate egg-shell calcifications

  • Can show signs of concurrent heart failure, pneumonia, or neoplasm

  • Fast and economic screening examination

Disadvantages
  • Often normal in uncomplicated acute idiopathic pericarditis

  • Small to moderate sized effusions may not cause an abnormal cardiac silhouette

VI. What are the contraindications for the alternative imaging techniques?

CT with and without IV contrast
  • Renal failure (risk of contrast-induced nephropathy with iodinated contrast)

  • Pregnancy

  • Contrast allergy may be a relative contraindication

MRI with and without IV contrast
  • Renal failure (risk of nephrogenic systemic fibrosis with gadolinium)

  • Metallic foreign bodies or implanted devices that are not MRI compliant

  • Pregnancy during the first trimester may be a relative contraindication

Plain-film radiographs
  • No significant contraindications exist. Some institutions may require consent for pregnant patients.