10

response to NSAIDs, early use of corticosteroids, high

CRP, and severe pericardial LGE on CMR.18 Patients who

do not achieve remission and have symptoms for >4 to 6

weeks but <3 months before resolution no longer have

acute pericarditis, and are labeled as having incessant

pericarditis, which can be more aggressive, whereas

chronic pericarditis requires >3 months of symptoms. As

with acute pericarditis, the presentation of recurrent or

incessant/chronic pericarditis can be either inflammatory

or noninflammatory, a distinction that significantly influences therapeutic approaches.

4.2.2. Evaluation and Multimodality Imaging

Evaluation starts with a thorough history, physical examination, electrocardiogram, and laboratory tests,

especially elevation in sedimentation rate and CRP, along

with troponin levels if myocarditis is suspected (Figure 5).

In the presence of personal and family history or risk

factors of infections, autoimmune diseases, or malignancies, associated investigations should be performed.1

Multimodality cardiac imaging has become a crucial

pillar in the evaluation of pericarditis. Transthoracic

echocardiography (TTE) remains the first-line imaging

modality for assessing suspected pericarditis.1,3 Although

often normal, pericarditis findings on TTE may include

presence of pericardial effusion (without or with tamponade), pericardial thickening, features of constrictive

physiology, and/or myocardial involvement in the setting

of myo-pericarditis (such as left ventricular systolic

impairment and/or regional wall motion abnormalities)

(Table 4).1 TTE can be serially used to monitor for

improvement or worsening of these abnormal findings

when present (Table 5). TTE’s main limitation is the

inability of tissue characterization to identify and grade

pericardial inflammation. TTE will also provide additional

information regarding cardiac chamber size and function,

valvular abnormalities, pulmonary hypertension, and

aortic diseases. Transesophageal echocardiography and

stress echocardiography are not generally required for

diagnosing pericarditis.

CMR has become a valuable comprehensive secondline imaging modality in the diagnosis, risk stratification, and surveillance (including response to therapy) of

pericarditis.19 CMR should be considered in patients with

acute complicated, incessant, recurrent, or chronic pericarditis, especially when diagnostic uncertainties exist;

patients who do not respond to standard first-line therapies and/or in whom escalation of therapies is planned;

and patients with suspected pericardial complications

such as complex effusions and/or constrictive physiology

(Table 5).1 The main CMR findings of pericarditis include

pericardial late gadolinium enhancement on phasesensitivity inversion recovery sequence (ideally fatsuppressed) indicating neovascularization/inflammation

(Figure 6, and new grading criteria Figure 7), increased

pericardial signal on T2-short tau inversion recovery

sequence indicating edema, pericardial thickening (>3

mm) especially on black-blood spin echo sequence, and

pericardial effusion, whilst features of constrictive physiology may also be observed (Table 4).1,19 With adequate

treatment leading to resolution of the acute pericarditis

flare, pericardial edema disappears and pericardial effusion and constriction may improve, whereas pericardial

late gadolinium enhancement lags behind clinical

improvement and typically decreases but not entirely

resolves into the chronic phase in those with recurrent,

incessant, or chronic pericarditis, before disappearing

either after a longer period of resolution or in patients

with burned out calcific constrictive pericarditis.1,20

CCT is the preferred modality in the assessment of

pericardial calcifications in constrictive pericarditis. Other

TABLE 4 Characteristic Imaging Features in Pericarditis

TTE CCT CMR

n Normal findings in

some patients. Pericardial thickening

n Noncalcified pericardial thickening

(>3 mm)

n Thickening of

pericardium at

T1-weighted BB

images (>3 mm)

n Segmental wall motion abnormalities or

pathological

myocardial strain

values (in case of

myocarditis)

n Enhancement of the

thickened visceral

and parietal

surfaces of the

pericardial sac at

late postcontrast CT

scan

n Enhancement of

pericardium on

LGE sequence

(inflammation) and

T2-STIR sequence

(edema) consistent

with active inflammation and neovascularization (of

prognostic

importance)

n LGEþ/T2-STIRþ:

acute/subacute phase

or recurrent flares

n LGEþ/T2-STIR-:

subacute or chronic

phase

n LGE-/T2-STIR-: resolution or end-stage/

calcific phase

n PEff with or without

CTP (present in

40%-50% of cases)

n PEff presence. CT

attenuation values

of the PEff may help

distinguish between

exudative and transudative fluid (on

noncontrast CT)

n PEff presence. High

signal intensity on

T1-weighted BB

images is suggestive

of exudative PEffs

n Sign of CP (often

transient)

n Loss of the normal

sliding between

pericardial layers

during the cardiac

cycle is one feature

consistent with

pericarditis

Adapted with permission from Klein et al.1

BB ¼ black-blood; CCT ¼ cardiac computed tomography; CMR ¼ cardiac magnetic

resonance; CP ¼ constrictive pericarditis; CT ¼ computed tomography; LGE ¼ late

gadolinium enhancement; PEff ¼ pericardial effusion; T2-STIR ¼ T2-short tau inversion

recovery; TTE ¼ transthoracic echocardiography.

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11

CCT findings in pericarditis may include the presence of

pericardial effusion, thickening, and inflammation on

delayed contrast sequence (although less accurate than

CMR) (Table 4).1,3 While CCT is not primarily used for

diagnosing pericarditis, it can be valuable for preoperative planning in cardiac surgeries, such as pericardiectomy. Additionally, CCT is more useful in

assessing other differential diagnoses of chest pain, such

as acute aortic syndromes, pulmonary embolism, and

coronary artery disease, although disadvantages include

radiation exposure and, when iodinated contrast is used,

FIGURE 6 Hallmarks of Pericarditis on Cardiac Magnetic Resonance

(A) Black-blood spin echo sequence axial image showing pericardial

thickening (arrow). (B) T2-short tau inversion recovery sequence shortaxis image showing pericardial edema (arrow). (C) Phase-sensitive

inversion recovery sequence short-axis images with fat suppression

showing pericardial late gadolinium enhancement indicating inflammation (arrow). Adapted with permission from Klein et al.1

TABLE 5

Recommendations for Diagnostic Evaluation,

Multimodality Cardiac Imaging, and Management

for Pericarditis

Recommendation Class

Thorough history recording (including symptoms

description and duration, risk factors,

assessment of systemic inflammatory

diseases), physical examination (auscultation

of rubs), and ECG (for pericarditis changes) as

part of evaluation for pericarditis

Recommended

Assessment of the presence of systemic

inflammation by means of C-reactive protein,

fever, neutrophil leukocytosis, and presence

of pericardial and pleural effusion to target

specific treatments

Recommended

TTE for evaluating and surveillance of pericardial

effusion, signs of tamponade, constriction,

and myocardial involvement of pericarditis

Recommended

CMR for initial evaluation of pericarditis in terms

of pericardial LGE, edema, thickening,

effusion, signs of constriction, and

myocardial involvement for diagnosis and risk

stratification, especially for complicated/

indeterminant cases

Recommended (recurrent/

incessant pericarditis)

Reasonable (acute

pericarditis)

CMR for assessing treatment response and

surveillance of pericarditis

Reasonable (recurrent/

incessant pericarditis)

Not recommended (acute

pericarditis)

CCT for evaluation of other chest pain causes

other than acute pericarditis

Reasonable

CCT for routine assessment of pericarditis Not recommended

High-dose aspirin or NSAID in combination with

colchicine (3 mo, acute; 6 mo, recurrent) as

first-level therapies for pericarditis (aspirin is

preferred in case of concomitant ischemic

heart disease)

Recommended

Anti–IL-1 agents may be considered in acute

pericarditis with the inflammatory phenotype

when other therapies are contraindicated,

ineffective, or not tolerated

Reasonable

Corticosteroid use should be restricted to acute

pericarditis cases that are refractory or

intolerant to other therapies (usually lowmedium doses)

Reasonable

Anti–IL-1 agents in recurrent/incessant

pericarditis after failure of first-level

therapies and/or corticosteroids, especially

with evidence of inflammatory phenotype

Recommended

Corticosteroids after failure of first-line therapies

for current/incessant pericarditis, especially

without evidence of C-reactive protein

elevation or specific conditions (eg,

autoimmune diseases)

Reasonable

In high-volume experienced pericardial surgical

centers, radical pericardiectomy is an

alternative option for patients who do not

respond to medical therapy for pericarditis

Reasonable

Exercise restriction for $1 mo after pericarditis

diagnosis or flare (maximal heart rate <100

beats/min regardless of activity) until clinical

remission

Recommended

Adapted with permission from Klein et al.1

CCT ¼ cardiac computed tomography; CMR ¼ cardiac magnetic resonance; ECG ¼

electrocardiogram; IL-1 ¼ interleukin-1; LGE ¼ late gadolinium enhancement; NSAID ¼

nonsteroidal anti-inflammatory drug; TTE ¼ transthoracic echocardiography.

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risks of kidney disease and contrast allergy. Use of nuclear

imaging such as fludeoxyglucose-positron emission tomography for assessing pericarditis is currently limited to

the research setting or in patients who cannot have CMR

(ie, claustrophobia, gadolinium allergy, severe obesity).21

4.2.3. Management

Contemporary management of pericarditis aims to

control symptoms and prevent complications (mainly

recurrences) and hospitalizations.22 First-line pharmacological treatment includes dual anti-inflammatory therapy with colchicine (3 months following first flare,

$6 months following first recurrence) and NSAIDs or

aspirin (starting at high dose and tapering after symptoms

resolve and inflammatory markers normalize) (Tables 5

and 6). Acid suppression therapies (eg, proton-pump inhibitors) are often concomitantly prescribed with NSAIDs

for gastric protection.1 Exercise restriction for $1 month

(maximal heart rate <100 beats/min with physical activity) until clinical remission is important.23 Increased heart

rate can trigger pericardial inflammation by enhancing

the frequency of friction of pericardial layers. In patients

with autoimmune pericarditis, the focus should be on

treating the underlying autoimmune condition first, as

the pericarditis often improves or resolves with that

alone. Hospital admission may be necessary in complicated high-risk cases, such as large pericardial effusion

and/or tamponade, severe pain refractory to first-line

therapies, and symptomatic constrictive pericarditis. Of

note, prompt diagnosis and therapy are recommended for

FIGURE 7 Proposed Pericardial Late Gadolinium Enhancement Grading Criteria by Cardiac Magnetic Resonance

4.2 mm

2.3 mm

2.4 mm

LGE 5.2 mm

4.4 mm

6.4 mm

Qualitative Assessment of LGE Severity

1) Determine LGE extent at 3 short

 axis slice locations

 • basal, middle, and apical slices

2) Determine circumferential extent

 on each slice

 • 50% threshold

3) Measure pericardial LGE thickness

 • 3-mm threshold

A

None

None

No pericardial enhancement

Trivial

Enhancement present, but

not reaching mild criteria

B

Mild

LGE Mild

• ≥50% circumferential

 extent, <3 slices, ≤3 mm

OR

• <50% circumferential

 extent, <3 slices, >3 mm

C

Moderate

LGE

Moderate

• ≥50% circumferential

 extent, 3 slices OR >3 mm

 (not both);

 OR

• <50% circumferential

 extent, 3 slices, AND >3 mm

C

Severe

LGE

10 • ≥50% circumferential

 extent, 3 slices AND >3 mm

Severe

D

Pericardial LGE severity grading criteria on CMR PSIR-LGE sequence (fat-suppressed sequence suggested), based on pericardial enhancement thickness and

circumferential extent on short-axis imaging at basal, mid, and apical slices. Adapted with permission from Klein et al.1 CMR ¼ cardiac magnetic resonance;

LGE ¼ late gadolinium enhancement; PSIR-LGE ¼ phase-sensitive inversion recovery late gadolinium enhancement.

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- , 2025: - – - Diagnosis and Management of Pericarditis