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.
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