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.