Pericarditis is defined as inflammation of the pericardium. It is normally found in association with cardiac, thoracic or wider systemic pathology and it is unusual to manifest on its own.
The diagnosis of pericarditis is based on clinical criteria and supplemental imaging information 1.
According to the 2015 ESC Guidelines for the diagnosis and management of pericardial diseases the diagnosis can be made if ≥2 of the following four criteria are met 1:
- pericarditic chest pain
- pericardial rubs
- new widespread ST elevation and/or PR depression
- new or worsening pericardial effusion
Supporting findings include the following:
- elevated inflammatory markers (CRP, ESR, WBC)
- imaging findings on cardiac CT or cardiac MRI suggesting pericardial inflammation
Classically, patients present with abrupt, pleuritic, positional left precordial chest pain after a viral prodrome. The pain is relieved in the sitting position when leaning forward and exacerbated when supine. Tuberculous pericarditis may present with constitutional symptoms, including fever, night sweats, anorexia, and weight loss. The physical exam may demonstrate:
- a pericardial friction rub
- classically triphasic, two components in diastole and one in systole
- may be transient
- signs of tamponade
- diffuse ST-segment elevation (STE)
- with upward concavity
- the STE in lead II > lead III
- absence of reciprocal changes or Q waves
- lead aVR demonstrates ST-segment depression
- this lead also may demonstrate PR segment elevation
- diffuse PR segment depression
- excluding the aforementioned (lead aVR)
- later, T wave inversions may develop
In general, infection is the most common cause of pericarditis. Infection accounts for two-thirds of cases while noninfectious causes account for the remaining one-third 9.
Pericarditis can be divided into subtypes according to morphology:
- serous pericarditis
- suppurative (purulent) pericarditis
- tuberculous (caseous) pericarditis
- fibrinous pericarditis
- hemorrhagic pericarditis
There may be an increased cardiothoracic ratio with a globular or 'flask-shaped' outline if there is co-existing pericardial effusion. Manifestations of cardiogenic pulmonary edema may also be present.
Echocardiography is recommended when the pericardial disease is suspected and may demonstrate 11:
- pericardial thickening
- indication for hospitalization when new and large
- cardiac tamponade
- elevated filling pressures
Patients who have a preserved ejection fraction but symptomatic heart failure may (with a suggestive clinical history) be examined for occult constrictive pericarditis, features of which include:
- right and left atrial enlargement
- mitral/tricuspid inflow pulsus paradoxus
- in the absence of an effusion
- annulus paradoxus
- elevated filling pressures with a preserved mitral septal annular velocity (septal e')
- annulus reversus
- tissue Doppler of the mitral annuli reveals a septal e' > lateral e'
- the lateral e' is normally always higher than the septal e'
At contrast-enhanced CT, enhancement of the thickened pericardium generally indicates inflammation 1.
Focal FDG uptake may be demonstrated in some cases.
Usually, GRE cine, T1, T2 black-blood/STIR and IR GRE sequences are performed. In the setting of suspected pericardial constriction, real-time cine sequences should be acquired 12,13. The presence of an arrhythmia may induce artefacts. For specific features please refer to subtype articles.
The normal pericardial thickness is considered 2 mm while a thickness of over 4 mm suggests a pericarditis 2,3.
Edema of the visceral and parietal pericardium, depicted in T2 black-blood/STIR images, and enhancement usually assessed with late gadolinium enhancement (LGE) images are additional specific MRI features 12-14.
In addition, cardiac MRI has the ability to assess the myocardium in regard to concomitant myocarditis and viability in a post-myocardial infarction setting or to detect myocardial infarction, if previously unknown.
- 1. Adler Y, Charron P, Imazio M, Badano L, Barón-Esquivias G, Bogaert J, Brucato A, Gueret P, Klingel K, Lionis C, Maisch B, Mayosi B, Pavie A, Ristic AD, Sabaté Tenas M, Seferovic P, Swedberg K, Tomkowski W. 2015 ESC Guidelines for the diagnosis and management of pericardial diseases: The Task Force for the Diagnosis and Management of Pericardial Diseases of the European Society of Cardiology (ESC)Endorsed by: The European Association for Cardio-Thoracic Surgery (EACTS). (2015) European heart journal. 36 (42): 2921-2964. doi:10.1093/eurheartj/ehv318 - Pubmed
- 2. Wang ZJ, Reddy GP, Gotway MB et-al. CT and MR imaging of pericardial disease. Radiographics. 2003;23 Spec No : S167-80. doi:10.1148/rg.23si035504 - Pubmed citation
- 3. Kovanlikaya A, Burke LP, Nelson MD et-al. Characterizing chronic pericarditis using steady-state free-precession cine MR imaging. AJR Am J Roentgenol. 2002;179 (2): 475-6. AJR Am J Roentgenol (citation) - Pubmed citation
- 4. Sechtem U, Tscholakoff D, Higgins CB. MRI of the abnormal pericardium. AJR Am J Roentgenol. 1986;147 (2): 245-52. AJR Am J Roentgenol (citation) - Pubmed citation
- 5. Alter P, Figiel JH, Rupp TP et-al. MR, CT, and PET imaging in pericardial disease. 2012;doi:10.1007/s10741-012-9309-z - Pubmed citation
- 6. Breen JF. Imaging of the pericardium. J Thorac Imaging. 2001;16 (1): 47-54. J Thorac Imaging (link) - Pubmed citation
- 7. Olson MC, Posniak HV, Mcdonald V et-al. Computed tomography and magnetic resonance imaging of the pericardium. Radiographics. 1989;9 (4): 633-49. Radiographics (citation) - Pubmed citation
- 8. Suchet IB, Horwitz TA. CT in tuberculous constrictive pericarditis. J Comput Assist Tomogr. 16 (3): 391-400. - Pubmed citation
- 9. Murillo H, Restrepo CS, Marmol-Velez JA et-al. Infectious Diseases of the Heart: Pathophysiology, Clinical and Imaging Overview. Radiographics. 2016;36 (4): 963-83. doi:10.1148/rg.2016150225 - Pubmed citation
- 10. Oyama-Manabe N, Yabusaki S, Manabe O, Kato F, Kanno-Okada H, Kudo K. IgG4-related Cardiovascular Disease from the Aorta to the Coronary Arteries: Multidetector CT and PET/CT. (2018) Radiographics : a review publication of the Radiological Society of North America, Inc. 38 (7): 1934-1948. doi:10.1148/rg.2018180049 - Pubmed
- 11. Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y, Tomkowski WZ, Thiene G, Yacoub MH. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. (2004) European heart journal. 25 (7): 587-610. doi:10.1016/j.ehj.2004.02.002 - Pubmed
- 12. Jan Bogaert, Marco Francone. Cardiovascular magnetic resonance in pericardial diseases. (2009) Journal of Cardiovascular Magnetic Resonance. 11 (1): 1. doi:10.1186/1532-429X-11-14 - Pubmed
- 13. Cardiac MRI: Part 2, Pericardial Diseases. (2012) American Journal of Roentgenology. 197 (4): W621-34. doi:10.2214/AJR.10.7265 - Pubmed
- 14. Imazio M, Pivetta E, Palacio Restrepo S, Sormani P, Pedrotti P, Quarta G, Brucato A, Bubbico E, Dal Corso M, Milazzo A, Quattrocchi G, Andriani M, Lobetti Bodoni L, Davini O, Sironi S, Giannattasio C, Giustetto C, Bogaert J, Adler Y, Bucciarelli Ducci C, De Ferrari GM. Usefulness of Cardiac Magnetic Resonance for Recurrent Pericarditis. (2020) The American journal of cardiology. 125 (1): 146-151. doi:10.1016/j.amjcard.2019.09.026 - Pubmed
- 15. Ünal E, Karcaaltincaba M, Akpinar E, Ariyurek OM. The imaging appearances of various pericardial disorders. (2019) Insights into imaging. 10 (1): 42. doi:10.1186/s13244-019-0728-4 - Pubmed