Pericardial calcification

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Pericardial calcification is usually seen in individual patients with a history of pericarditis and may be associated with constrictive pericarditis. 

Pathology

Although historically infective pericarditis was the most common cause, a wide variety of insults can lead to calcification of the pericardium. 

Radiographic features

Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves 2. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated constrictive pericarditis.

Plain radiograph
  • a curvilinear density at the extreme margin of the cardiac silhouette (better on lateral view)
  • extension of calcification over the pulmonary outflow tract (better on lateral view)
  • dilated ​left atrium: due less pericardial investment, even with pericardial constriction, mimicking mitral stenosis

Tuberculous calcifications are the most dense, in the atrioventricular grooves and appear as thick, amorphous oblique circles or arcs of calcifications then spread over the atria and ventricles 2.

Treatment and prognosis

Patients with pericardial calcification may be asymptomatic. If present, symptoms are usually those of heart failure caused by the pericardial calcification restricting the ability of the heart to distend with blood in diastole. In some patients this can be controlled medically, but if the calcification is established this is often ineffective. Pericardiectomy, although not without risk, is potentially curative 3.

Differential diagnosis

The differential diagnosis for pericardial calcifications include:

  • -<p><strong>Pericardial calcification</strong> is usually seen in individual patients with a history of <a href="/articles/pericarditis">pericarditis</a> and may be associated with <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>. </p><h4>Pathology</h4><p>Although historically infective pericarditis was the most common cause, a wide variety of insults can lead to calcification of the pericardium. </p><ul>
  • -<li>
  • -<a href="/articles/pericarditis">pericarditis</a>: <a href="/articles/tuberculous-pericarditis">tuberculous</a>, fungal, viral or <a href="/articles/purulent-pericarditis-1">pyogenic</a>
  • -</li>
  • -<li>previous trauma (<a href="/articles/haemopericardium">haemopericardium</a>)  </li>
  • -<li>cardiac surgery</li>
  • -<li>collagen vascular diseases: as <a href="/articles/systemic-lupus-erythematosus-thoracic-manifestations-1">systemic lupus erythematosus</a>
  • -</li>
  • -<li><a title="uremic pericarditis" href="/articles/uremic-pericarditis">uremic pericarditis</a></li>
  • -<li>later sequelae of <a href="/articles/rheumatic-heart-disease">rheumatic heart disease</a>
  • -</li>
  • -<li>malignant pericardial involvement (e.g. <a href="/articles/mediastinal-teratoma">mediastinal teratoma</a>)</li>
  • -<li>post-radiotherapy<sup> 1</sup>
  • -</li>
  • -<li>idiopathic</li>
  • -<li>
  • -<a title="calcified pericardial mass" href="/articles/calcified-pericardial-mass">calcified pericardial mass</a> or cyst</li>
  • -</ul><h4>Radiographic features</h4><p>Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves <sup>2</sup>. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>.</p><h5>Plain radiograph</h5><ul>
  • -<li>a curvilinear density at the extreme margin of the cardiac silhouette (better on lateral view)</li>
  • -<li>extension of calcification over the pulmonary outflow tract (better on lateral view)</li>
  • -<li>dilated ​left atrium: due less pericardial investment, even with pericardial constriction, mimicking mitral stenosis</li>
  • -</ul><p>Tuberculous calcifications are the most dense, in the atrioventricular grooves and appear as thick, amorphous oblique circles or arcs of calcifications then spread over the atria and ventricles <sup>2</sup>.</p><h4>Treatment and prognosis</h4><p>Patients with pericardial calcification may be asymptomatic. If present, symptoms are usually those of <a href="/articles/congestive-cardiac-failure">heart failure</a> caused by the pericardial calcification <a href="/articles/constrictive-pericarditis">restricting</a> the ability of the heart to distend with blood in diastole. In some patients this can be controlled medically, but if the calcification is established this is often ineffective. Pericardiectomy, although not without risk, is potentially curative <sup>3</sup>.</p><h4>Differential diagnosis</h4><p>The differential diagnosis for pericardial calcifications include:</p><ul>
  • -<li>
  • -<a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>: in the setting of heart failure with concern for constrictive pericarditis or <a href="/articles/restrictive-cardiomyopathy">restrictive cardiomyopathy</a>, calcifications are highly suggestive of the former</li>
  • -<li>
  • -<a href="/articles/chronic-adhesive-pericarditis">chronic adhesive pericarditis</a> in the absence of constriction: less dense with a more patchy distribution <sup>4</sup>
  • -</li>
  • -<li>
  • -<a href="/articles/rheumatic-pericarditis">rheumatic pericarditis</a> <sup>5</sup>
  • -</li>
  • -<li>
  • -<a href="/articles/myocardial-calcification">myocardial calcification</a>: more left-sided and localized calcification (e.g. over the cardiac apex from prior <a href="/articles/myocardial-infarction">infarction</a>) <sup>6,7</sup>
  • -</li>
  • +<p><strong>Pericardial calcification</strong> is usually seen in individual patients with a history of <a href="/articles/pericarditis">pericarditis</a> and may be associated with <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>. </p><h4>Pathology</h4><p>Although historically infective pericarditis was the most common cause, a wide variety of insults can lead to calcification of the pericardium. </p><ul>
  • +<li>
  • +<a href="/articles/pericarditis">pericarditis</a>: <a href="/articles/tuberculous-pericarditis">tuberculous</a>, fungal, viral or <a href="/articles/purulent-pericarditis-1">pyogenic</a>
  • +</li>
  • +<li>previous trauma (<a href="/articles/haemopericardium">haemopericardium</a>)  </li>
  • +<li>cardiac surgery</li>
  • +<li>collagen vascular diseases: as <a href="/articles/systemic-lupus-erythematosus-thoracic-manifestations-1">systemic lupus erythematosus</a>
  • +</li>
  • +<li><a title="uremic pericarditis" href="/articles/uremic-pericarditis">uraemic pericarditis</a></li>
  • +<li>later sequelae of <a href="/articles/rheumatic-heart-disease">rheumatic heart disease</a>
  • +</li>
  • +<li>malignant pericardial involvement (e.g. <a href="/articles/mediastinal-teratoma">mediastinal teratoma</a>)</li>
  • +<li>post-radiotherapy<sup> 1</sup>
  • +</li>
  • +<li>idiopathic</li>
  • +<li>
  • +<a title="calcified pericardial mass" href="/articles/calcified-pericardial-mass">calcified pericardial mass</a> or cyst</li>
  • +</ul><h4>Radiographic features</h4><p>Pericardial calcification is more common over the right side, anterior and diaphragmatic aspects of the heart in the atrioventricular grooves <sup>2</sup>. Calcifications over the left ventricle or cardiac apex are rare, unless pericardial calcification is extensive. It is important to assess for signs of associated <a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>.</p><h5>Plain radiograph</h5><ul>
  • +<li>a curvilinear density at the extreme margin of the cardiac silhouette (better on lateral view)</li>
  • +<li>extension of calcification over the pulmonary outflow tract (better on lateral view)</li>
  • +<li>dilated ​left atrium: due less pericardial investment, even with pericardial constriction, mimicking mitral stenosis</li>
  • +</ul><p>Tuberculous calcifications are the most dense, in the atrioventricular grooves and appear as thick, amorphous oblique circles or arcs of calcifications then spread over the atria and ventricles <sup>2</sup>.</p><h4>Treatment and prognosis</h4><p>Patients with pericardial calcification may be asymptomatic. If present, symptoms are usually those of <a href="/articles/congestive-cardiac-failure">heart failure</a> caused by the pericardial calcification <a href="/articles/constrictive-pericarditis">restricting</a> the ability of the heart to distend with blood in diastole. In some patients this can be controlled medically, but if the calcification is established this is often ineffective. Pericardiectomy, although not without risk, is potentially curative <sup>3</sup>.</p><h4>Differential diagnosis</h4><p>The differential diagnosis for pericardial calcifications include:</p><ul>
  • +<li>
  • +<a href="/articles/constrictive-pericarditis">constrictive pericarditis</a>: in the setting of heart failure with concern for constrictive pericarditis or <a href="/articles/restrictive-cardiomyopathy">restrictive cardiomyopathy</a>, calcifications are highly suggestive of the former</li>
  • +<li>
  • +<a href="/articles/chronic-adhesive-pericarditis">chronic adhesive pericarditis</a> in the absence of constriction: less dense with a more patchy distribution <sup>4</sup>
  • +</li>
  • +<li>
  • +<a href="/articles/rheumatic-pericarditis">rheumatic pericarditis</a> <sup>5</sup>
  • +</li>
  • +<li>
  • +<a href="/articles/myocardial-calcification">myocardial calcification</a>: more left-sided and localised calcification (e.g. over the cardiac apex from prior <a href="/articles/myocardial-infarction">infarction</a>) <sup>6,7</sup>
  • +</li>

References changed:

  • 1. Paniagua González M & Sánchez Alegre M. Extensive Pericardial Calcification Secondary to Radiotherapy, Causing Mixed Constrictive-Restrictive Pathology. BJR Case Rep. 2017;3(4):20170036. <a href="https://doi.org/10.1259/bjrcr.20170036">doi:10.1259/bjrcr.20170036</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30363214">Pubmed</a>
  • 2. Ferguson E & Berkowitz E. Cardiac and Pericardial Calcifications on Chest Radiographs. Clin Radiol. 2010;65(9):685-94. <a href="https://doi.org/10.1016/j.crad.2009.12.016">doi:10.1016/j.crad.2009.12.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20696295">Pubmed</a>
  • 3. Khalid N, Hussain K, Shlofmitz E. Pericardial Calcification. 2022. - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30855926">Pubmed</a>
  • 4. Valentin Fuster, Richard Walsh, Robert Harrington. Hurst's the Heart, 13th Edition: Two Volume Set. (2010) ISBN: 9780071636469 - <a href="http://books.google.com/books?vid=ISBN9780071636469">Google Books</a>
  • 5. Dan Longo, Anthony Fauci, Dennis Kasper et al. Harrison's Principles of Internal Medicine, 18th Edition. (2011) ISBN: 9780071748896 - <a href="http://books.google.com/books?vid=ISBN9780071748896">Google Books</a>
  • 6. MacGregor J, Chen J, Chiles C, Kier R, Godwin J, Ravin C. The Radiographic Distinction Between Pericardial and Myocardial Calcifications. AJR Am J Roentgenol. 1987;148(4):675-7. <a href="https://doi.org/10.2214/ajr.148.4.675">doi:10.2214/ajr.148.4.675</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/3493647">Pubmed</a>
  • 7. Stuart J. Hutchison. Principles of Cardiovascular Radiology. (2011) ISBN: 9781437704051 - <a href="http://books.google.com/books?vid=ISBN9781437704051">Google Books</a>
  • 1. Paniagua González Miguel, Sánchez Alegre María Luisa. Extensive pericardial calcification secondary to radiotherapy, causing mixed constrictive-restrictive pathology. (2017) BJR|case reports. 3 (4): 20170036. <a href="https://doi.org/10.1259/bjrcr.20170036">doi:10.1259/bjrcr.20170036</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/30363214">Pubmed</a> <span class="ref_v4"></span>
  • 2. Ferguson EC, Berkowitz EA. Cardiac and pericardial calcifications on chest radiographs. (2010) Clinical radiology. 65 (9): 685-94. <a href="https://doi.org/10.1016/j.crad.2009.12.016">doi:10.1016/j.crad.2009.12.016</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/20696295">Pubmed</a> <span class="ref_v4"></span>
  • 3. Nauman Khalid, Sarah A. Ahmad, Evan Shlofmitz. Pericardial Calcification. (2021) <a href="https://www.ncbi.nlm.nih.gov/pubmed/30855926">Pubmed</a> <span class="ref_v4"></span>
  • 4. Fuster V. Hurst's the Heart. McGraw-Hill Professional Pub. (2010) ISBN:0071636463. <a href="http://books.google.com/books?vid=ISBN0071636463">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0071636463?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0071636463">Find it at Amazon</a><div class="ref_v2"></div>
  • 5. Dan Longo, Anthony Fauci, Dennis Kasper et-al. Harrison’s Principles of Internal Medicine, 18E. McGraw-Hill Prof Med/Tech. (2012) ISBN:007174889X. <a href="http://books.google.com/books?vid=ISBN007174889X">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/007174889X?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=007174889X">Find it at Amazon</a><div class="ref_v2"></div>
  • 6. Macgregor JH, Chen JT, Chiles C et-al. The radiographic distinction between pericardial and myocardial calcifications. AJR Am J Roentgenol. 1987;148 (4): 675-7. <a href="http://www.ajronline.org/content/148/4/675.abstract">AJR Am J Roentgenol (abstract)</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/3493647">Pubmed citation</a><div class="ref_v2"></div>
  • 7. Stuart J. Hutchison. Principles of Cardiovascular Radiology. (2011) <a href="https://books.google.co.uk/books?vid=ISBN9781437704051">ISBN: 9781437704051</a><span class="ref_v4"></span>
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