Pericarditis

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.