New Diagnostic Criteria for Acute Pericarditis: A Cardiac MRI

Perspective
Nov 05, 2015   |  J. Ronald Mikolich, M.D., FACC

Expert Analysis

Currently, the diagnosis of acute pericarditis is based on demonstrating at least

two of the following four criteria: 1. Non-ischemic chest pain, 2. ECG evidence of
PR depression or ST segment deviation, 3. Detection of a pericardial rub on
auscultation and 4. Pericardial e垭�usion on 2-D echocardiography.1 It is well known
that ECG evidence is often lacking and that a pericardial rub is often 垒�eeting and
not easily detected. 2-D echocardiography is capable of detecting moderate and
large pericardial e垭�usions, but small or very small e垭�usions are di垀�cult to see,
especially when image quality is compromised by a narrow intercostal echo
window, chronic lung disease or obesity. From a practical standpoint, the only
reliable criterion is symptomatic chest pain, often making the diagnosis di垀�cult to
de垒�nitively establish. The chest pain of pericarditis can vary from severe
substernal discomfort to a vague "ache". The chest pain is usually positional, not
related to exertion and often radiates to the neck, ridge of the trapezius muscle or
shoulder. As an ancillary diagnostic tool, laboratory con垒�rmation of an
in垒�ammatory process, such as an elevated sed rate, is sometimes used to support
the diagnosis of acute pericarditis, but is non-speci垒�c.

With most in垒�ammatory disorders, accumulation of interstitial water is a

component of the pathologic process. Magnetic resonance imaging (MRI) is ideally
suited for the detecting the exact anatomic location of non-physiologic water,
including edema. With T2 weighted cardiac MRI pulse sequences, water appears
"bright" and is easily detected, given the excellent spatial resolution of MRI (see
Figure 1). T2 weighted imaging does not require contrast injection. However, use
of gadolinium contrast with delayed enhancement imaging o垭�ers an additional
method of detecting abnormal redistribution of water into the pericardial
interstitium (see Figure 2). Both Figures 1 and 2 are examples of pericarditis
without associated pericardial e垭�usion. A more "classic" example of pericarditis
with e垭�usion is shown in Figure 3.

Data presented at the 2014 American College of Cardiology Annual Scienti垒�c

Session2 attempted to systematically study a series of chest pain patients for
evaluation of pericarditis by cardiac MRI using T2 weighted and late gadolinium
imaging sequences. Of 44 patients with CMR documented pericarditis, only 5
(11.3%) had a pericardial e垭�usion on their 2-D echo study. Only 22 patients (50%)
had a pericardial rub, while only 24 (54.5%) had ECG changes suggestive of
pericarditis. Overall, 18 of 44 patients (41%) would not have met current criteria
for a diagnosis of pericarditis, if not for CMR 垒�ndings. Furthermore, 66% of these
patients with CMR documented pericarditis had a small pericardial e垭�usion on
their CMR study, which was missed on a 2-D echo study (see Figure 4). These data
suggest that a substantial portion of patients with chest pain have pericarditis
detectable by CMR imaging, but not by currently accepted diagnostic criteria.

Figure 1: Di垭�use
enhancement of the
pericardium characteristic
of acute pericarditis using
a T2 weighted pulse
sequence. The brightness
is due to increased water
content related to the
in垒�ammatory process.
Figure 2: Di垭�use
abnormal pericardial
uptake of gadolinium,
diagnostic of pericarditis,
using delayed
enhancement imaging 10
to 15 minutes after
contrast injection. The
in垒�ammatory process
allows redistribution of
gadolinium into the
pericardial interstitium.
Note the absence of a
pericardial e垭�usion.
 Figure 3: Image A shows
a circumferential Figure 4: An example of a
pericardial e垭�usion with very small pericardial
Steady State Free e垭�usion detected with
Precession (SSFP) SSFP cardiac magnetic
imaging. Image B shows resonance imaging, but
abnormal gadolinium of missed with 2-D
both the parietal (red echocardiography.
arrow) and visceral
(yellow arrow) pericardial
surfaces. Note that the
visceral uptake of
gadolinium is not di垭�use,
but rather "focal" along
the inferolateral surface
of the heart. The non-
di垭�use pattern is more
commonly seen in
pericarditis.

Boniface et al 3 presented data at the 2014 American Heart Association Scienti垒�c

Sessions on CMR evaluation of 708 patients with chest pain who had a negative
ischemic evaluation, but complained of persistent chest discomfort and were
labeled as non-cardiac chest pain. Cardiac MRI of these patients revealed that 143
of 708 (20.2%) had evidence of pericarditis, undetected by standard diagnostic
criteria. These data suggest that 1 out 5 patients with recurrent chest pain and a
negative ischemic evaluation may actually have pericarditis. More recent data
from Morgenstern et al 4 showed that that the likelihood of detecting pericarditis
with CMR in patients with chest pain was highest among patients under age 40,
and much less likely in patients over age 60 (see Figure 5).

Figure 5: Distribution of pericarditis by age group. Note that very few patients with cardiac MRI
垒�ndings of pericarditis have no chest pain.
 Although
cardiac
MRI
appears
to be
useful in
detecting
pericardial

in垒�ammation, the imaging studies have not had direct con垒�rmation with histologic
data. Since pericarditis is usually not associated with mortality, autopsy correlation
with pre-mortem MRI imaging is non-existent. However, indirect validity is
suggested by data from our institution2 which showed that the colchicine-NSAID
therapeutic regimen, demonstrated to be e垭�ective by Imazio et al 5, was similarly
e垭�ective when pericarditis was diagnosed with cardiac MRI. However, the study
was small and will require validation with larger trials. Until cardiac MRI detection
is fully validated, the practical value of cardiac MRI imaging in patients with
suspected pericarditis is its ability to detect pericardial e垭�usion, which is often
missed with trans-thoracic 2-D echocardiography. Cardiac MRI is also clinically
useful for patients with recurrent chest pain after a negative ischemic evaluation.
These patients are often very frustrated when a cause for their chest discomfort
cannot be de垒�nitively identi垒�ed, even with an extensive "non-cardiac" diagnostic
evaluation. Many of these patients, on the verge of being labeled with a
psychogenic etiology, are extremely grateful when their pericarditis is detected
with cardiac MRI, opening the door for e垭�ective therapy and most importantly,
relief of their persistent symptoms.
As cardiac MRI imaging criteria for pericarditis develop, further studies will be
required to determine if abnormal T2 weighted imaging and abnormal delayed
enhancement imaging 垒�ndings are both required to establish the diagnosis.
Would evidence from just one of the CMR imaging pulse sequences su垀�ce or are
both necessary? As T1 and T2 mapping capability becomes more widely available,
further insight into CMR imaging for pericardial disease is likely to follow. This
issue is further compounded by the fact that CMR imaging is not widely used in
the United States, as it is usually available only at specialized referral centers and
regarded as an expensive research tool by many practicing physicians. CMR
imaging of pericarditis with T2 weighted pulse sequences is easy, requires no
contrast and takes less than 垒�ve minutes to perform, yielding valuable diagnostic
information especially when the patient is known to have a recent negative
ischemic evaluation. A CMR study could be quickly and easily done while a patient
is in the Emergency Department, and potentially save an unnecessary admission
for recurrent chest pain. Likewise, a CMR study to exclude pericarditis after a
negative "observation" admission for chest pain could save repeat visits to the ED.
Use of cardiac MRI for detection of pericarditis also has cost saving implications.
In the author's geographic area, the cost to the healthcare system (i.e. actual
reimbursement) of a cardiac MRI study is $496.20, while that of a visit to the
Emergency Department is $1,013.84, a di垭�erence of 200%.

In summary, on the basis of these recent data, the following groups of patients
seem most likely to bene垒�t from cardiac MRI imaging for pericarditis:

1. Patients with persistent chest pain after a negative ischemic evaluation.

2. Patients with non-ischemic chest pain suspicious for pericarditis, but no
detectable e垭�usion on 2-D echocardiography.
3. Patients with non-ischemic chest pain suspicious for pericarditis, but a poor
quality or non-diagnostic 2-D echo study.
4. Patients with recurrent chest pain after a negative ischemic evaluation and a
negative "non-cardiac" chest pain evaluation.
5. Younger patients with atypical chest discomfort and a low likelihood of
coronary atherosclerotic disease.

Since the advent of cardiac MRI's capability to actually visualize pericardial

in垒�ammation, consideration of the diagnosis when dealing with a patient
complaining of chest pain is now more appropriate. Radiologists often espouse a
phrase "you see what you know and you know what you see". Now that we can
"see" pericarditis, we will know it better.
DISCLOSURES:
Use of gadolinium for delayed enhancement cardiac MRI imaging is considered an
"o垭�-label" use of this contrast agent.

References

1. Imazio M. Pericarditis (Beyond the Basics). UpToDate 2013;

http://www.uptodate.com/contents/pericarditis-beyond-the-basics
2. Mikolich J, Kley J, Boniface N et al. Are new diagnostic criteria for pericarditis
needed? J Am Coll Cardiol. 2014;63(12_S).
3. Boniface N, Kley J, Lisko J et al. Non-cardiac chest pain: Is it really? Circulation.
2014;130:A12863.
4. Morgenstern D, Kley J, Lisko J et al. Chest pain in patients under age 40: Are we
getting it right? J Am Coll Cardiol 2015;65(10_S).
5. Imazio M, Brucato A, Cemin R et.al. A randomized trial of colchicine for acute
pericarditis. N Engl J Med 2013;369:1522-8.

Clinical Topics: Noninvasive Imaging, Pericardial Disease,

Echocardiography/Ultrasound, Magnetic Resonance Imaging

Keywords: American Heart Association, Anti-In垒�ammatory Agents, Non-Steroidal,

Auscultation, Autopsy, Chest Pain, Colchicine, Depression, Echocardiography, Edema,
Electrocardiography, Emergency Service, Hospital, Gadolinium, Heart Diseases, In垒�ammation,
Lung Diseases, Magnetic Resonance Imaging, Obesity, Pericardial E垭�usion, Pericarditis,
Pericardium, Physical Exertion, Shoulder, Super垒�cial Back Muscles

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